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APPLICATION FOR SANITARY PERMIT yylz?' ,�GyGJ <br /> D I L H R ° COUNTY <br /> oE�RnT MM OF (PLB 67) UNIFORM SANITARY PERMI # <br /> e� IDpl1eTRV,Li1BOn 6 MUfnHnFELRT1pn5 / <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. <br /> —See reverse side for instructions for completingthisapplication. PLEASE PRINT <br /> PRO TY TY OWN MAILING ADDRESS �7 <br /> 1 /✓2M / -oUS rl-� J a .S OI <br /> PROPERTY LOCATION CITY: <br /> VILLAGE: <br /> ' 1/4 VE 1/4,8 26 , Tvo, N, R /y B (or) W N o S'c LOTNUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> � r ! /mac/ SSS ov31 77 <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: [`S] Public (Specify): w C'4'" S/ ) <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 /> N7 Seepage Bed ❑ Seepage Trench ❑ Seepage Pit d Hold my 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: <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 7;3 <br /> ER SUPPLY: <br /> (Minutes LLpeiir inch): REQUIRED (Square Feet): PR/OPOSED (Square Feet): �Q JJ�% <br /> f 'T /.>�`� O / 596 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): Signatur : ^ MP/MPRSW No.: Phone Number: <br /> I <br /> '7J4 <br /> J4ui c'A /�.,.SJ i4 d f7/;) 63s- 8' <br /> Plumber's Ad ress: Name of Designer: <br /> y/ 3 SM <br /> ' r_/ s%- S oc vmt- w— S-y ro I <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: O Date: ❑ Disapproved <br /> p5� �' Q pl ❑ Owner Given Initial <br /> 0 / of Approved Adverse Determination <br /> &Ilissson for Disapproval: /('✓ <br /> Alternate course(T)of Action Available: <br /> DILHR SBO-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />