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ws—si^ APPLICATION FOR SANITARY PERMIT <br /> DILHR COUNTY <br /> oERRRnnEm oc (PLg 67) UNIFORM SANIT RY PERM T# <br /> mousrRV,LRBr s'wmnn RELnnons <br /> D/ <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 /> PR PERT7 OW ERMAILING ADDRESS <br /> 14 IQ O Q G rer% 4 7 . <br /> PROPERTY LO ION / CITY: <br /> 1/4/UF N,/4, S 3 , TO R /,I' (Or) W TOWN OF: jrq C <br /> LOT N MBER IBLOCK NUMBER ISUBDIVISION NAME NEWREST ROAD, LAKE OR LAy DMARK STATE PLAN I.D. NUMBER <br /> 0r SQ.1d <br /> TYPE OF BUILDING OR USE SERVED �{ <br /> X 1 or 2 Family Number of Bedrooms. ,( Tj Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 2!�Nevv 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 Cl Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> EJ 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 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: C: <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): PRO'P'OSED (Square Feet): <br /> 3 Y ( o { d ® Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage s stem shown on the attached plans. <br /> N e of/�l umber (Pr-ntl: Sign MP/MPRSW No.: Phone Numbber- <br /> tT d�E+I' C 0 t iJ SI Q /J <br /> lumber's Aydress.: Nam Design r: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign ture of Issuing Agent: Fee: Date: ❑ Disapproved <br /> LlOwner Given Initial <br /> a a Approved <br /> Adverse Determination <br /> ason for Disapproval: C✓ <br /> Alternate coursels)of Action Available: <br /> DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />