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D I L H R APPLICATION FOR SANITARY PERMIT dat <br /> —COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT # <br /> OEPRRTmEnT DF <br /> InpUSTRV,LRBOR 6Ml1RIRn RELRT10n5 <br /> ,7/37 /�/ 1J, <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, <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTYPWNER L MAILING ADDRESS !� fes,, <br /> 't <br /> S 4aw so 11 row S / ' ���d L4yr LoQt r /—f,4 G <br /> PROPERTY LOCATION CITY: +-���- <br /> ,TW1/4SE1/4, S 13 , Ty0 N, R /sTOWN oF:! (0r) W �/`t L /� d N <br /> LOT NUMBER BLOC NU BER SUBDIVISION NAMEST ROAD, LAKE OR LANDMAR STATE PLAN I.D. NUMBER <br /> Al A- Br'rch ' FLan <br /> vi I <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms. j ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> >TNew 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 /> ❑ 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 S <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 WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): ,fir <br /> j"tQ u 3 ) F Private ❑ Joint ❑ Public <br /> 1,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> e of pDlumwber ($int): Sign tore: , MP/MPRSW No.: Phone Number: <br /> c o TrIC fT /�o �/hs d �us'y 7i� IP66 <br /> Plumber's Address: Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig ture of Issuing Agent: Fee: Date: ❑ Disapproved <br /> ❑ Owner Given Initial <br /> p0 s'7�Oi� Approved Adverse Determination <br /> ason for Disapproval: r� <br /> Alternate courses)of Action Available: <br /> DI LH R-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />