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uu.sMo_lo APPLICATION FOR SANITARY PERMIT <br /> �- D I L H R QUNTV <br /> (PLB 67) UNIFORM SANI ARY PERMIT # <br /> OEPRRTinEnT OF l <br /> Incx_STRV.LRBOR6MUTRrIRELRTN S `/ /^/� ()J <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8Yzx 11 inches in size, of IT <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNERMAILING ADDRESS <br /> /730 ,. �3u t a.. ANS, .S S_Ie <br /> ROPE V O ATION CITY: T <br /> W1/45E1/4, S3E <br /> S , TYO, N, RX (or) W vOWNOE. V C krdh <br /> LOT NUMBER BLOC;NUMBER SUB VISION NAME REST QAA, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> AR Y / Gr/ L <br /> X 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> X New System Tank Replacement ❑ Repair <br /> X Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> X 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 t7 J X <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: L4 t <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 Feetl: PROPOSED (Square Feet):/ <br /> ( (9 y 3 '�_. 50Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name ofP r <br /> umber,(Prin Si ure: MP/MPF SW No.: Phone Number: <br /> R 1Q , c ; tr�.n 1 a oa <br /> Plumber's AdQQQQQress: 1 Namf Designer: <br /> 'W` <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> QoY� �� ❑ Owner Given Initial <br /> IVY Approved Adverse Determination <br /> Ri!ason for Disapproval: F• <br /> Alternate course(s)of Action Available: <br /> Cl LHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />