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[7-7Dw ^^$1^ APPLICATION FOR SANITARY PERMIT <br /> I L H R r,l� SANITARY 'RUNTY <br /> oeRRRTmenT or (PLB 67) UNIFORM SANITARY PERMIT # <br /> 1110USTR LR 01R&HLImRnRELRTIDnS 99,/4�6gY77 \ <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/zx 11 inches in size. J <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS $ ` ZZ <br /> A/ Pel 141 1_-Cd,1,V /P ti ,cam M v <br /> %O ERS LOCATION VI CITY: <br /> /4 -.'94, SOWN, T N, R (or)Q OWN OF U. 5'/ <br /> LOT NUMBER BLOCK NUMBER ISUBDIVISION NAME EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> 0,1117 Kt /J <br /> TYPE OF BUILDING OR USE SERVED <br /> �<1 or 2 Family Number of Bedrooms: TEI Public (Specify): /J J- , <br /> THIS PERMIT IS FOR A: <br /> New System ❑ Tank Replacement ❑ Repair <br /> Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS <br /> IS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> IX 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 <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 Tk Capacity <br /> Lift Pump/anSiphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREAABSORPTION AREA MATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet) <br /> : <br /> Private ❑ Joint ❑ Public <br /> 1,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print): Sig ure: MP/MPRSW No.: Phone Number: <br /> / _E - /�kfi cc 1/s )2W-_7�9D <br /> Plumber's Address: Name of Designer: <br /> T`i� 6apr. f L <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign t of Issuing A nt: Fee: Date: ❑ Disapproved <br /> O ❑ Owner Given Initial <br /> �Approved Adverse Determination <br /> eason for Disapproval: <br /> Alternate coursels)of Action Available: <br /> DILHR-SBD 6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />