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D I L H R APPLICATION FOR SANITARY PERMIT rT <br /> COUNTY <br /> (PLB 67) UNIFORM SAyITARY PERMIT # <br /> � DEPiiRTTEnT OF i/ <br /> nWSTRV,LRBOR 6 HUnYir1RELRTIOnS <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 /> PROPEF;TV OWNER MAILING ADDRESS // /-- <br /> rt.r Lv r e.Vr- vrr Wt L"r 4 /vF <br /> PROPERTY LOCATION CITY: T L <br /> S F- 1/4 N"f1/4, S a$ , TVQ N, R /S! (or) W OWN OF: T 4 e- �I _r n <br /> LOTH`BER BLOCK NUMBER SUBDIV ISIQN NAME r SOT;YD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED / A CL/ <br /> LX 1 or 2 Family Number of Bedrooms: e1-- Tj Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System ❑ Tank Replacement ❑ Repair <br /> X Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> 9 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/ � 'j„f' V X <br /> Lift Pump Tank/Siphon Chamber S` 0 <br /> Holding Tank capacity <br /> Manufacturer: 7-A4 C— <br /> IF <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 AREAABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet 1: PROPOSED (Square Feet): <br /> l 4/1 /C 4/ 1P X 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): f Si ure: ,, // MP/MPRSW No.: jPhone Number: <br /> D 0 4_ 9 7141 P66 i1/J7 <br /> Plum er's ddress: Narr]@ of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signatu f Issuing A nt: ee: Date: ❑ Disapproved <br /> C O 29/y�(r� owner Given Initial <br /> L�� L' ' '�O"t• ny Approved Adverse Determination <br /> 71, <br /> ea for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DILHR-Seo-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />