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APPLICATION FOR SANITARY PERMIT <br /> DILHR <br /> [IL'1'I-L�"� OUNTY <br /> (PLB 67) UNIFORM SAN TARY PERMIT # <br /> -elleeeeeee .EW pT . �/ <br /> OF /(� <br /> STRY.LRBOR6MUTRr1RELRT10115 ,? .(t <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. O� <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PRRRFRTv OWNER MAILING A DRESS <br /> O`✓u+-r ro .Q�__ Tn r�n. D a 4a w.- w l <br /> PROPERTY LOCATION ,/ CITY: / <br /> /Uw1/4 NW 1/4, S /y, T 7 UN, R J�P! (or) W F!NT17AOR <br /> F O ! L Q n d <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> VA X)h >(/ A. C c C <br /> TYPE OF BUILDING OR USE SERVED <br /> X 1 or 2 Family Number of Bedrooms: ❑ 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 /> �6 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 -7j-0 <br /> x <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: w �' <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 /> (M inL�u,t/gs per inch): REQUIRED (Square Feet), <br /> PROPOSED (Square Feet): <br /> 7 q / U' 4`3' 1 Qi Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name ofplumber (Print): Sig yre: MP/MPRSWNo.: Phone Number: <br /> oder I c �C )� e � n r V� d 4) 65 1` 7is),6� r7 <br /> Plumber's A dress: Name of Design <br /> w e � :7Tr I. s-VP <br /> jr. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig a of Iss -ng Agent: F e: Date: ❑ Disapproved <br /> wrier Given Initial <br /> Approved Adverse Determination <br /> eason for Disappr val: <br /> Alternate course(s)of Action Available: <br /> DI LHRSBD 6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />