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eeeeeei w.°D^�^ APPLICATION FOR SANITARY PERMIT <br /> � D I LHR COUNTY <br /> oeRRRTmenT oa (PLB 67) UNIFORM SANITARY PERM T # <br /> - InDUSTRy,LRBOR&HUTPn RELRroonss <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm, Code for the system, on paper not less than 8/zx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> P OPERTY ER MAILING ADDRESS / <br /> tl�U rO NW R r �0 0 _e_^L- L <br /> PROPERTY LOCATION CITY: <br /> N -ci/4 NE1/4, S 13 , T WN, R /1601 (or) W TOWN OF: Wt s S <br /> LOT rBER I BLOCK NUMBER SUBDIVI N NAME N ST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> NA /t� $ Qss 4tit <br /> TYPE OF BUILDING OR USE SERVED <br /> IBJ 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 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 /> 3d 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. <br /> Site <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <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: P'R/OPOSED (Square Feet): <br /> CL_ r 10 7 � %, ' Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na of P)umber IPrintl: Si re: t MP/MPRSW No.: Phone Number: <br /> , 4 <br /> k�nt 63 0 J-7 6�b- y� <br /> Plumber's Adr Name of Designer: <br /> ess: <br /> W—e 3 7", Y' laJ i, .f'e/if P I OL <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig of Issuing A ant: 1ee; Date: ❑ Disapproved <br /> u✓ ❑ Owner Given Initial <br /> �,�L -*Approved Adverse Determination <br /> son for Disapproval: <br /> .04 <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />