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APPLICATION FOR SANITARY PERMIT �/�1 <br /> DILHR Urn NIT`R COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT# <br /> nMST YLR1 flF <br /> � Ir1W5TRV,LRBOW 6HUTMIFELFT10n5 <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8Y�x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPS et (OWNER n MAII -iL ADDF},�-e'b f- � I Yu l <br /> P PERTY LOCATION CITYPry lI1I: \\/0011 ,L,, 11-1 lJ <br /> IS 61/4 N614, S , N, R S W o ce )t �leffl <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAMEREST ROA AKE R LANDMARK STATE PLAN I.O. NUMBER <br /> rPI <br /> TYPE OF BUILDING OR USE SERVED <br /> �1 or 2 Family Number of Bedrooms: Tj Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> X New System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> I,a,l Seepage 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 10 0 C2 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: 01 e <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 Pup hon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA 1JtIATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> —3-- I S 0 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for nstallati on of the private sewage system shown on the attached plans. <br /> Name of Plumber ( ri ): Signa ure: MP(MPRSW No.: Phone Num e <br /> e dtit <br /> - s��y ( e <br /> Plumber's Add r ss: Name of D signer: <br /> �o-e P (� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa a of Issuing nt: F e: Date: ❑ Disapproved <br /> "o / El <br /> OwnerDeInitial <br /> Determination Adverse Determinnation <br /> son for Disapproval <br /> Alternate courses)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />