Laserfiche WebLink
JJ�� APPLICATION FOR SANITARY PERMIT �/y' <br /> t � OI LHR ✓M SANT OUNTV <br /> _ (PLB 67) UNIFORM SANITARY PERS T <br /> sz;'0 ii /i G <br /> —Attach complete plans in accord with s. H 63.05,Wis.Adm.Code for the system,on paper not less than B'6x 11 inches in size, <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPER TV OWNER MAILING ADDRESS <br /> Rf: YhAfz� <br /> PROPERTY LOCATION CITY: <br /> 1/45E1/4, S , T`.L�, N. R /i (or W vaii <br /> GE: ✓i .r'sy�n/ <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN LD.NUMBER <br /> A/A- )i A x} Gane C,zeL? Ags 20 7 /J-+ <br /> TYPE OF BUILDING OR USE SERVED <br /> t�' 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> L 1( New System ❑ Tank Replacement ❑ Repair <br /> 1J Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petitionfor Modification <br /> 7 <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> X1 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 n issues <br /> ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. <br /> TotalSol Pielo , site Steel Fiberylass Plauia <br /> Gallons Tanks Con Cons,recces <br /> Septic Tank Capacity <br /> Llh Pump Tank/Siphon CEamder <br /> Holding Tank capacity <br /> Manufacturer: <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Ton" Rof Prefab, Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Cme"pectetl <br /> Septic Tank Capacity <br /> Lilt Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTIOAREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED ISyN me r') <br /> PgOPOSED (Square Feed: <br /> �— <br /> -.31 4/ 37 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 Plumber lPrsntl: Sign me: MPI^^ A,.. Phone Number: <br /> a0-7 (7,j vv3so� � <br /> Plumber s Adtlreas'. Name of Designer: . <br /> Qr3 0 Sys ti <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of issuing <br /> /)Agent: F9(ec: Date: ❑ Disapproved <br /> h <br /> Approved Adverse Determination <br /> Eason Igr Disapproval: <br /> Alternate coarsels)of Action Available: <br /> DILHRSBo 6398 in,5/82) DISTRIBUTION: Original to County. One Copy To; Bureau Of Plumbing,Owner,Plumber <br />