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APPLICATION FOR SANITARY PERMIT1=7-.:: ILH R �� COUNTV <br /> (PLB 67) UNIFORM SANITARY PERM T# <br /> enT OF <br /> TRV,LRBOR 6Nlln%ir1gELRTIOr15 �/, ,// /0{) <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8%x i t inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING r DDB*aS <br /> S S.M %.-v e, b S /-r r- W S <br /> PROPERTY LOCATION CITY: �-- ` <br /> /VE1/4uE1/4, S 36, WO N, R/$—E (or) W OWN OF T C /1 .f0 <br /> LOT NUVBER BLOCI�I�XBER SUBDIVL,SiON NAME REST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> N /V� 4/Ar Sq.,d Cafe <br /> TYPE OF BUILDING OR USE SERVED <br /> LN 1 or 2 Family Number of Bedrooms: ❑ Public (Specify: <br /> THIS PERMIT IS FOR A: <br /> ❑ New System ❑ Tank Replacement ❑ Repair <br /> 34' Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> M 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 Sail Conditions. <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> �. Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity /�• 7,3`0 <br /> Lift Pump Tank/Siphon Chamber .T`O 0 v <br /> Holding Tank capacity <br /> Manufacturer: W G <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <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 l: PROPOSED <br /> ,(`Scriare Feet): <br /> �J low 'V & 7 a ® Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of lumber (Print): Si ure: MP/MPRSW No.: Phone Number: <br /> oJer ck k.:, r / e216C9 (71T )AW-y/S7 <br /> Plumber' Address: NP of Designer: <br /> I—V 7v r- w;, s Yds <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa of Issuing A Fee: Date: Ll Disapproved <br /> p (,o ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> on for Disapproval: <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 />