Laserfiche WebLink
F77 <br /> conSIn APPLICATION FOR SANITARY PERMIT <br /> � ILHR a �r OUNTY <br /> (PLB 67) UNIFORM SANITARY PERMI # <br /> STPY,LRBOR 6 HUmAn RELRTIOnS /\ <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size, <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> PROPERTY LOCATION I <br /> Ne 1141Y41-114, S ,� , T U N, R *lDr W TOWN OF: S-oTT" <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> 7 Vel 4 c iN <br /> TYPE OF BUILDING OR USE SERVED <br /> Z<or 2 Family Number of Bedrooms. f ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> Yw 1�w System ❑ Tank Replacement ❑ Repair <br /> El Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> 17T!�eepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy <br /> ❑ Existing, For Which A Previous Permit Is On File, Permit # issued <br /> ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity �jv L�— <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: To ^j <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> 9?15'rivate ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print): Signature: /MPRSW No.: Phone Number: <br /> Plumber's Address: Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> SV <br /> ure of Issuing Agent: Fee: Date: ❑ Disapproved <br /> ��""' I1' / /_ F/ l ❑ Owner Given Initial <br /> y/�/eo" �Z 424,E 6 f� �W / Approved Adverse Determination <br /> 1`14son for Disapproval: iC a <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />