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Ea(�� <br /> wlsconsln -' APPLICATION FOR SANITARY PERMIT �J <br /> DILHR /O " �� COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT# <br /> OEPRRTTEnT OF <br /> InOUSTRV,LRBOR 6 MUTRn RELRTIOnS zl- D / r7(� <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> if FO� AS` Ce /�' =L'�S%E &4 <br /> PRO Fi / CjTr V ``1t11 <br /> t1/4 1/4, S ' , T Q, N, R /�C r W TOWN OF: <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> L Zy- <br /> TYPE OF BUILDING OR USE SERVED <br /> k'_lor 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 1 ew 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 /> �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 ) ) L../ <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: isEc <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 /> /P-30 /"0 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: j� DAP/MPRSW No.: Phone Number: <br /> i, f Ok ' t �1J1,20 <br /> Plumber's Address: Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign ture of Issuing Agent: Fee: Date: ❑ Disapproved <br /> le ❑ Owner Given Initial <br /> Approved <br /> ' Adverse Determination <br /> R ason for Disapproval: > <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 />