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77"""_'" APPLICATION FOR SANITARY PERMIT <br /> D I L H R ��hG COUNTY <br /> o`DUST .LR or <br /> (PLB 67) UNIFORM SANITARY PERMt\T# <br /> mousrw,�ga"w. swumanr canons 3 611J <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. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER C MAILING ADDRESS t <br /> PROPERTY LOCATION _ V11 I ACE: <br /> WW 1/451/4, S T yQN, R SiW TOWN OF: TQ—C- ifSd <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME �(SROAD LAKE ORL AHNDIVARK STATE PLAN I.D. NUMBER <br /> o-c <br /> TYPE OF BUILDING OR USE SERVED 7)iT A/ <br /> X1 or 2 Family Number of Bedrooms. ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 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 /> 7<Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdiny 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 0O d <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: C <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: EEI <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA <br /> (Minutes per in1JfIgTER SUPPLY: <br /> ch): REQUIRED (Square Feet l: PROPOSEDp(Square Feetl: <br /> JR2 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na a of umber (Print): S re: MP/MPRSW No.: Phone Number: <br /> tr <br /> 'e.1-1 U . � 0 �0 � 7/I-) A WS <br /> Plumbei s gddres N of s' ner. P <br /> W e la g !�e r (a1 t <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent:.� Fee-/,' Date: El Disapproved <br /> Owner Given Initial <br /> � �•;fc .�(� �1 pt //� _6 APProved ❑ <br /> Adverse Determination <br /> ason for Disapproval: fJ <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 />