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Risen APPLICATION FOR SANITARY PERMIT <br /> DILHR COUNTY <br /> (PLB 67) <br /> III—wrow—E— <br /> UNIFORM SANITARY PERMIT# <br /> ys7oP C nas9) <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 S3-r7 <br /> e I M a s-rr r f o I v T v T c�.rY < <br /> PROPFFRTY}.t ATION // -may., / <br /> Sfd,%Sa�/4, S , T UN, R/W t (or) W TOWN OF: <br /> LOT CUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARATE PLAN I.D. NUMBER <br /> ��El7 hton Zv/T�e K ST <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 2-T New System ❑ Tank Replacement ❑ Repair <br /> LReplacement Sail Absorption System ❑ Revision jJJ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> MJ Seepaye, Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> J System-In-Fill ❑ InGroundPressure ❑ Vault Privy ❑ Pit Privy <br /> ❑ <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 Si <br /> #o! Prefab- ta <br /> Gallon Tenks Con Con uctetl Steel Flbergles plastic <br /> Septic Tank Capacity O <br /> 7 <br /> Lift Pump Tank/Siphon chamber <br /> Holding Tank capacity <br /> Manufacturer: _ L :y <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound [] In-Ground Pressure <br /> Total =of Prefab. Site <br /> Gallon Tanks Con rete Constructed steel Fiberglas Plas[Ic <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufac <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per mcM1l: REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> 7 '7 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Ngo I )umbel IPripGNper <br /> : Si MPIMPRSW No.: Phone um : <br /> K�Fa rrfc � (hT 0 U3ASy 16G6- 1/.r <br /> Plumbers Af De igne <br /> Nr. <br /> ess. I—tae , s— gsJ� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent Fee: Date: <br /> l <br /> ,y OJ ❑ Disapproaed <br /> LJ � A -?7- / J ❑ Ow er Glv n Initial <br /> Ative u Dee <br /> mission for Disapproval: <br /> Alternate courses)of Action Available: <br /> DILHR SBD 6398 (R.5182) DISTRIBUTION: Original m County, One Copy To: Bureau of Plumbing,Owner,Plumber <br /> J <br />