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APPLICATION FOR SANITARY PERMIT �!_7/)' <br /> D I L H R FORM SA COUNTY <br /> (PLB 67) UNIFORM SANITARY PE MIT # <br /> eo aecawrmenr or• <br /> n00000sion nousrn I nT OF swumwn rsecnnons <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8Ysx 11 inches in size. <br /> —See reverse side for instructions for completing this applicatign. PLEASE PRINT <br /> TY <br /> PROPER0 ER MAILING ADDRESS r <br /> 41 ��1 UPY P . ( -l� 'i+r 14 I his, v%6ti <br /> PROPERTY LOCATION I CITY: 7 <br /> SW1/45E1/4, S j3 N, R1� "' N OF X304 P1 vo r <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME RESTe.LA LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> O, Qs( ` n WOO& RIJPr <br /> TYPE OF BUILDING OR USE SERVED 1 <br /> 1 or 2 Family Number of Bedrooms. p` ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 9 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 /> A Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> ❑ System-In-FiII ❑ 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: 1"-,o C-L`t'tC Ai-ed, <br /> A/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): PROtPO/SED (Square Feet): <br /> IS - 3:3 -2-0y.O l o 7 z-8 X Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for i stallation of the private sewage system shown on the attached plans. <br /> Name ofP lumber tl <br /> (P In ' Signa e: MP/MPRSW No.: Phone Number: <br /> � lS G'Qr7irb � <br /> Plum ddress: en Name of signer: <br /> Z W e �Os�—e r 1.t► t N to <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign a of Issuing nt: Fee: Date: El Disapproved_T Ll Owner Given Initial <br /> �-pproved Adverse Determination <br /> ason for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DILHR SBD 6398 (R.5/821 DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />