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�_��^ APPLICATION FOR SANITARY PERMIT <br /> � D I L H R COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT # <br /> OEPRRTTEnT OF- InWSTRV,LRBOR6Ml1mRn RELRTIOnS <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 /> PROPGER'4 OI{Yf11ER G` ` MAILING ADDRESS <br /> f?DDR ESS/ Iv <br /> �Q/ 9 Y 1A 7 P;, ',I <br /> PRO`P,ERTYJDCATION CITY: <br /> 1/4 16-1/4, S , WO, N, R Irf (or) W wN o To c IT-JO r, <br /> LOT 7UMBER BLOCK NUMBER SUBDIVISION NAME EST ROAD,LAKE OR LAND ARK STATE PLAN I.D. NUMBER <br /> I Npr A/A rr� � .ZS �a..� L,�r/f <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 /> ,N 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 /> 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 7,r0 <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 # f Pr <br /> oefab. 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): PR (Square(Square Feet): <br /> Y1// (9 �F � �— IK 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 P/umber (Print): Signyre: MP/MPRSW No.: Phone Number: <br /> /f a d e ric fC �-� o �r f/� d OS' lis) 866 c//J-7 <br /> Plumber's A dres Nam f Designer. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signat of Issuing t: Fee: Date: El El <br /> ElOwner Given Initial <br /> L2l lj�Approved Adverse Determination <br /> ;po5n for Disapproval: <br /> Alternate courses)of Action Available: <br /> OILHR SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />