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ns'n APPLICATION FOR SANITARY PERMIT <br /> ILHR <br /> COUNTY <br /> (PLB 67) <br /> EZ:: <br /> TRI LR Oc UNIFORM SANITARY PERMIT # <br /> TRV,LRBOR6MlJTRn RELnT10r15 xlO /O 7 //-Za —A <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size, <br /> ?g <br /> —See reverse side for instructions for completing this application. PLEASE PRINT _ <br /> P,R41rTV OWNER �^ M ,II L'I�NG ADDRESS t , 4" ,*< <br /> /T r �AD :. '��-a���l <br /> PROPERTY LOCATION CITY: JL / <br /> MAO 1/4 )V6'1/4, S JM" , T 4/UN, R / Q (or) W WN OF:TOI Q I O rI p[ <br /> LOT NU BER BLOCK NUMBER SUBDIVISION NAME S ROAD, LA E OR LANDMARK STATE PLAN I.D. NUMBER <br /> )v /v A N � �e 4 <L � L t d <br /> TYPE OF BUILDING OR USE SERVED <br /> Y 1 or 2 Family Number of Bedrooms: �, ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System 5C Tank Replacement ❑ Repair <br /> IV Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> X 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-o <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: Mound El In-Ground Pressure <br /> Total #of Prefab. 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 i ABSORPTION AREA WATER SUPPLY: <br /> (Min /7 <br /> (Minutes per inch): REQUIRED <br /> , <br /> (Square Feet): PROPOSED (Square Feet): <br /> eZ l U - � Z N 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 Ply mber (Print L/ Sign . MP/MPRSW No.: Phone Number: <br /> �J d ! / IG �- �IKI O.) Q 7,1 rX46 't/�i j <br /> Plumber's AdLlress. N;zfDe igner: <br /> �J <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signatwm of Issuin Agent: Fee: Date: ❑ Disapproved <br /> 6 u Tye ❑ Owner Given Initial <br /> lT-'• //�' O-13J Approved Adverse Determination <br /> Son for Disapproval: <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 />