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� Wisconsin Ill or APPLICATION FOR SANITARY PERMIT ��u <br /> COUNTY(PSB 67) UNIFORM SANITARY PERMIT# <br /> B <br /> 7 (/a a/7 <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8%x11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAI L,�vG ADDRESS <br /> X,CROe f'L`7L/ !�� I B Gf////�3s [.c��' S ydy <br /> PROPERTY LOCATI N CITY: <br /> VILLAGE: <br /> Nklilzc 1/4, S 3 , IN, RE (o W TOWN OF: t2=svF��✓ <br /> LOT NUMBER BLOCK NUMBER SUBDIV IS ON NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> 11,11} <br /> TYPE OF BUILDING OR USE SERVED <br /> X1 or 2 Family Number of Bedrooms: a Fr-j Public (Specify): <br /> TH,S PERMIT IS FOR A: <br /> rXR, New System ❑ Tank Replacement L1 Repair <br /> Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF 1111Tcc�cHHxIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> yel Seepage Bed ❑ Seepage Trench E-1SeepagePit ElHoldiny Tank <br /> r.� 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. g li-el <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): <br /> REQUIRED D'(Square Feet): PROPOSED (Square Feet): <br /> 1-37/ Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print): Sign re: MP/MPRSW No.: Phone Number: <br /> Plumber's Address: _ Na a of Designer: <br /> COUNTY/DEPARTM NT USE ONLY <br /> Signature of Issuing Agent: Fee:/ Daat /(�ttee: / p/ ❑ Disapproved <br /> �j6�7 / —O 7 App oved ❑ Owner Given Initial <br /> r Adverse Determination <br /> ason for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DI LHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />