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� D^_^ APPLICATION FOR SANITARY PERMIT <br /> 1 LHR (PLB 67) COUNTY <br /> ^aRBRTmenr OF UNIFORM SANITARY PERMIT$k <br /> snousrRV,LRRORSHuman RELRnons -;7 <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8Y x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> QLD [ZKE ✓l2 . .RGA/ Tiff <br /> PROPERTY LOCATION CITY: <br /> VILLAGE: <br /> 5uJ1/4S,!�_ 1/4, S'� , T 41 N, R/16 E (orMTOWN OF- :5 <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NA( F NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> /2 NA T9H v5cv5 K/uc2 <br /> E K 1= fn .vCa:A?_U 4 D6/ P-7 !Z. �t <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: �Z FP1LIlc (Specify): ��-- <br /> THIS PERMIT IS FOR A: <br /> ❑ New System Tank Replacement El Repair <br /> �41Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> Neepaye Bed ❑ Seepage Trench LJ Seepage Pit El Holding Tank <br /> System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy <br /> ❑ Existing, For Which A Previous Permit Is On File, Permit # 116A,' 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 Q <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: 7_,177.d . C r <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 (Squ'ar/e Feet): <br /> 3 V// y/`7 NPrivate ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na ofmber (Prints: Signa re: MP/MPRSW No.: Phone Number: <br /> ,uPlu.�/� I er- 3a (7/,-) 2.vv-3s0 <br /> Plumber's Address: Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si at a of Issuing ent: Fee: Date: ❑ Disapproved <br /> do / �D (J/ ❑ Owner Given Initial <br /> �iA �11?67� 6 7S 6 Approved Adverse Determination <br /> son for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DI LHR-SBD-6396 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />