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APPLICATION FOR SANITARY PERMIT <br /> D I L H RCOUNTY <br /> CIEPRFTm L TCF ���� ��) UNIFORM SANI ARY PERMI # <br /> - IITWSTRV, n00R6HurnonL LWT1Ons <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. UX <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PR ERTY/�WNER r MAILING AD9RESS <br /> c h e r ►, y— 4) h 4 I- <br /> pr <br /> PROPERTY LOCATION CITY: <br /> 1)LA1/4 A)W/4, S , TJ/� N, R /("90(or) W OWN OF: / `s .S <br /> LO )BER BLOCK NUMBER SUBDIVIS ON NAME ST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> / ,/ <br /> TYPE OF BUILDING OR USE SERVEvD, f-F__ <br /> 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System ❑ Tank Replacement ❑ Repair <br /> 2 Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> yW Seepage Bed ❑ Seepage Trench LM 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 -1 ~SO <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 /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ATI <br /> BSORPON AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> 1; 1 1/ V (a 7 Q X Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nameof P1u tuber (Print): S' atur MP/MPRSW No.: Phone Number: <br /> 0 d,u r d 0 SI? I I 12/1PFG <br /> Plumber's Addres : Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signatu3i of Issuing Agent: Fee: Date: ❑ Disapproved <br /> ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> n for Disapproval: <br /> Alternate courses)of Action Available: <br /> DILHR SBD 6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />