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��ynsconsin APPLICATION FOR SANITARY PERMIT _ <br /> � DILHR ' .�u ���?� COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT# <br /> �EPRRTTiIEnT OF <br /> - InOUSTgV,LFiBOg6HUTRn RELRTIOnS Fz <br /> //,�)(� Z,�) - �S`' ' 7 K/I775) <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 /> PROPERTI OWNER MAILING ADDRESS <br /> PROPERTY LOCATION CITY: <br /> "S `-YA '-Ile, VILLAGE: <br /> 1/4 1/4, S , T , N, R E (or) W TOWN OF: <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> El 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: 4 <br /> ❑ New System '> DEITan cement ❑ Repair <br /> El Replacement Soil Absorption System sion ❑ Privy <br /> EJ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOC <br /> El Seepage Bed ❑ Seepage Trench page Pit ❑ Holding Tank <br /> EJ System-In-Fill ❑ In-Ground Pressure It 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 ar oil ditions. <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Septic Tank Capacity Gallons Tanks Concrete Constructed <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: <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 /> ❑ Private ❑ 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): Si o 9 vrAa@ MP/ PRSW No.: Phone Number: <br /> cy <br /> Plumber's Address: f t ry yj Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: <br /> • ❑ Disapproved <br /> �( ❑ Owner Given Initial <br /> J �///� Approved Adverse Determination <br /> son for Disapproval: <br /> s -�-g7 <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 />