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ED. <br /> SOo^'s^ APPLICATION FOR SANITARY PERMITDILHR / pCOUNTY <br /> ERliRTi}IEnT OF \PLO ��' UNIFORM SANITARY PERM T# <br /> IOUSTRV,LRBOP&HUMFIMPELRTIOnS <br /> 79� 77 L/2 <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 /> PROPERT OWNE}, MAILING ADDRESS <br /> �� ! At W k) /yo w At aW6 o/ Qr <br /> PROPERTY LOCATION CITY: <br /> NE1/4,VE1/4, S ). , TV N, R/ B (or) IN TOWN OF: cSw( S f <br /> LOT NUMBER BLOCK NUMBER SUBDIVI51(;N NAME EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> /t/,/IL AI Es s 4e /�t <br /> TYPE OF BUILDING OR USE SERVED <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 /> ❑ 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 7Sf) <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 /> LEE <br /> Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA [WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nwof umber (PLntl: Si at re: MP/MPRSW No.: Phone Number: <br /> K C %{ e ,n r 030J ni 11'6 r <br /> Plumber's Address: NPof Designer: <br /> l�C <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa a of Issuing A t: �ffle: a a Date: <br /> El Disapproved <br /> ' Approved Owner Given Initial <br /> El <br /> Adverse Determination <br /> n for Disapproval: - <br /> Alternate courses)of Action Available: <br /> DILHR-SBD 6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />