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APPLICATION FOR SANITARY PERMIT <br /> COUNTYL (PLB 67) <br /> UNIFORM SANITARY PERM T # <br /> TEr1T OF <br /> OEPfYiT <br /> E In011SmRrlgElPT10115 <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8%x 11 inches in size. Jl <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PR RTYOWNER / r MAILING ADDRESS <br /> 4 4 C 4 74 r 1� r it x;L -P r 4 �� <br /> PROOP'ERTV�LC CATION CITY; <br /> 1/L4 lS 1/4, S TyQN, R { 11 (or) WT WNOF: S C-� <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> N A N i`s 4� F <br /> TYPE OF BUILDING OR USE SERVED <br /> X i or 2 Family Number of Bedrooms. ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> Sk New System XTank Replacement ❑ Repair <br /> �9 Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> 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 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: l.✓C <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 /> Y) 1 [5e Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> IN ie of Prumber (PrintSig yre: MP/MPRSW No.: Phone Number: <br /> Plumber's Ar/)_dress:.-/y-- Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signat a of Issuing Agent: F-e�er:p Da.7te: p ❑ Disapproved <br /> ,((�O,S� /-/B�O s /Approved ❑ Owner Given Initial <br /> Adverse Determination <br /> on for Disapprov : <br /> Alternate courses)of Action Available: <br /> DI LHR SBD 6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />