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APPLICATION FOR SANITARY PERMIT <br /> � D I L H R LA COUNTY <br /> (PLB 67) UNIFORIFOR M SANITARY PERMI # <br /> - pEPRPTR1EnT OF <br /> - InOUSTRV.LP60R 6HUnInF1 PELHTIOI'15 O/ ) O/ / <br />�i -Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. Oc r0 �] <br /> -See reverse side for instructions for completing this application. PLEASE PRINT <br /> PR j,TYOWNER MAILING ADDR_+ESS <br /> 6/11 /J-Q M;7 J roU o -- -5 yeo <br /> PROPERTY LOCATION CITY: c-� <br /> �-✓ C n <br /> ' 1/4&V 1/4, S -16 , TY-4, <br /> , N, R /y B (or) W WN OF: <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> S'S uUY 77 <br /> TYPE OF BUILDING OR USE SERVED <br /> ❑ 1 or 2 Family Number of Bedrooms: Public (Specify): ce, f �' ,� .Sr f <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 /> Seepage Bed ❑ Seepage Trench ❑ Seepage Pit Holding Tank <br /> EJ 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. Sae Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity 6 <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 #ofPrefab. Site $reel 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: f <br /> (Minutes per inch): REQUIRED (Square Feet l: PROPOSED (Square Feet): n C) <br /> 1 '—'70 � ,j 9i� ❑ 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): 7ME; <br /> MP/MPRSW No.: Phone Number: <br /> I _l /4u/ cin/ L!/ ,;t (7/y') 635 .22yk7 <br /> Plumber's Ad ress: Name of Designer: <br /> L// 3 Ste , h S / n Nm t- W— S- o <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> � <br /> Owner Given Initial <br /> 7 a J �9-�✓ Approved Adverse Determination <br /> ason for Disapproval: K✓ <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 />