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51^ APPLICATION FOR SANITARY PERMIT DILHR COUNTY <br /> 77 <br /> f]EPRRT 'E"TOF (PLI� s71 UNIFORM SANITARY PERM T # <br /> 1n0U%TRV,LRBOR6NrlrtYnI LRT1c1n5 <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8Y x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWN R MAILING AD RESr <br /> v `t W-e S / `e P"' 'al i <br /> PROPERTY LOCATION CITY: <br /> SW 1/0"X S 3Y, TgCN, R /6 J1 (or) W ki TOWN OE: d 4e it <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME REST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> PA N N l�eui K /? <br /> TYPE OF BUILDING OR USE SERVED <br /> ❑ 1 or 2 Family Number of Bedrooms. TE Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> K 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 7s <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 Tank Capacity <br /> Litt Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA rATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PR OPOSED (Square Feet): <br /> 63 V (7'6111 VPrivate ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N4we of lumber (Print): Si na re: MP/MPRSW No.: Phone Number: <br /> o err / a liar a eS 7ir)11616 Wi <br /> Plumber's Address: Name of Designer: , <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ure of Issuing Agent: Fee: Date: <br /> co Disapproved <br /> � /d_ D� ❑ Owner Given Initial <br /> dYd ✓ C 1 ArApproved Adverse Determination <br /> ason for Disapproval: J <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />