Laserfiche WebLink
w'=°o^_in APPLICATION FOR SANITARY PERMIT <br /> � �ILHR COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMI # <br /> �EPggTTEDT pF <br /> InoUSTR V,LRBOR&HUmRn RELRTIonS <br /> _a 79 / o <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 /> PROPERTY OWNER MAILING ADDRESS <br /> '—T d2 !7 H a i .ti si <br /> PROPERTY LOCATION CITY: _ <br /> : <br /> 1/4 1/4, S /3 , T5/?N, R / 'E{vr) W VILLAGEWN OF: /rF C1Soft/ <br /> LOT NUMBER I BLOCK NUMBER UIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> ey a Ng 4e)r ou -0- <br /> TYPE <br /> eTYPE OF BUILDING OR USE SERVED <br /> A 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> EX 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 0 <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 /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> 1 q/o I y/0 I m 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): Signa e: -` MP/MPRSW No.: Phone Number: <br /> �, s cc; lv�J yai� �3>+ -a�� <br /> Plumbers Address: Name of Designer: <br /> (/ .Sd J e w T S_t/ <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> Owner Given Initial <br /> pr/ <br /> 0 / ��Q 7 Approved ❑ <br /> 7� <br /> Adverse Determination <br /> Reason for Disapproval: FJ <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 />