Laserfiche WebLink
APPLICATION FOR SANITARY PERMIT <br /> (rDILHR <br /> (PLB 67) COUNTY <br /> OEFWPTTEnT OF UNIFORM SANITARY PERMIT # <br /> � InOU5TF4,LRBOR6MUmRn RELFTIODS 6c/a V �/i 83G) <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 // <br /> NG ADDRESS <br /> d -P r MAt / DQ r 4 f,y Lo <br /> PR PERTV LOCATION or I CITY: �// / <br /> S'leJ1/4 S"/4, S `)- , T ON, R / (or) W TOWN OF' O C/ " ^ d� m/ <br /> LOT NUN R BLOCK NU BER TSUBDIVISI N NAME AR EST ROAD, LAKE OR)_ANDMARK STATE PLAN I.D. NUMBER t4 0 <br /> YPE OF BUILDING OR USE SERVED //'I't� d/ <br /> W 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> New System Tank Replacement ❑ Repair <br /> X Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> .51 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 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: oe <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. $ite 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 inchl: REQ//UIRED (Square Feet): PROPOSED (Square Feet): <br /> 7 1p S & T � rK Private ❑ Joint ❑ Public <br /> I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nge of l umherr(Pri nt): Sign ore: MP/MPRSW No.: Phone Number: <br /> a �prlc <br /> Plumber's Addre s: N Des-gner: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ature of Issuing Agent: Fee: Date: <br /> /� � � ❑ Disapproved <br /> /�� ?J la! �/ //-_ �� ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> eason for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DI LHR SBD6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />