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APPLICATION FOR SANITARY PERMIT �` � <br /> DILHR `�j u r A) — COUNTY <br /> (PLB 67) SJIT <br /> UNIFORM Ap11TARY PER<�11T # <br /> rlCesTTEr1T OF / ) <br /> O�lSTR V,LR00R 6 FI4ITRrl RELRTIOrIS <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 /> P PERTY OWNER MAILING ADDRESS <br /> p I eS p l _ � n� c S (`t �u (/� SSI( <br /> PROPERTY LOCATION / CITY: l <br /> �1/��`1/4, S TN, R �rT VII V WN OB SCCI�1 <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAM AREST ROACGLKEPR LANDMARK STATE PLAN I.D. NUMBER <br /> 3 Z�, <br /> TYPE OF BUILDING OR USE SERVED <br /> X I or 2 Family Number of Bedrooms: a ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System Tank Replacement ❑ Repair <br /> IX 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 -750 / <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: r <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 /> _70_3 400 1 417,0 54 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for i stallation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Prin : Sign re' MP/MPRSW No.: Phone Number: <br /> ei(S )mac- ? S7 ( / - <br /> Plumber's Address Name of Designer: <br /> Z (S <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign ture of Issuing Agent: Fee: JD Date: ❑ Disapproved <br /> ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> ason 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 />