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WSCO^=^ APPLICATION FOR SANITARY PERMIT <br /> � D I L H R (PLB 67) rn —COUNTY <br /> UNIFORM SAN)TARY PERMIT # <br /> oewwwrmenr or / <br /> a� inousrw�,�weaws Humwnws�wnons ' <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 /> PR PERTY OWNER MAILING ADDRESS <br /> � <br /> . O, _3A ilIso, , iiW r 9 L <br /> PROPERTY LOCA ION CITY: <br /> UW 1/4�6E 1/4, SZ T3 , N, R E (or W vl NGF 1 <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME _[77FARESIQUA.V, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> eF-ers o.�. <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: Tj Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> X 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 <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity <br /> Lift Pump Tank/Siphon Chamber Q <br /> Holding Tank capacity <br /> Manufacturer: timc <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site $Leel Fiberglass Plastic <br /> Gallons Tanks Concrete I Constructed <br /> Septic Tank Capacity <br /> Liftfactu <br /> Pump/Siphon Chamber <br /> Manurer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> 3 _3 - 3 t4 Private ❑ Joint ❑ Public <br /> I, the undersigned, hereby assume responsibility fo installation of the private sewage system shown on the attached plans. <br /> Name of Plumber rin 1: Sign Lure MP/MPRSW No.: Phone Number: <br /> 1S -0 1;1)0 <br /> PI ber's Address: Name of esign r: <br /> Lr L LS �r <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> ❑ Owner Given Initial <br /> jr5d �- ��d5 APProved Adverse Determination <br /> son for Disapproval: ��, J <br /> Alternate course(s)of Action Available: <br /> DILR R-Seo-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />