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D I L H R APPLICATION FOR SANITARY PERMIT <br /> COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT # <br /> E.=- <br /> rlIX1$TRVLRBOR6MUTFr1RELRT10115 / <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8/2x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PRO RTY OWNER MAILING AD RESS <br /> C <5 ra6Tr D4 -< ` Q <br /> PROPERTY LOCATION CITY: <br /> Illi1/4, S as, T-/Q N, R /SE (or) W OWN OF: Q /l Stl F <br /> LOT_NUIvIBER BL�IOC/IC,NUMBER SUBDIVI$IQN NAME O '70�AD, LAKE OR,LAN DMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> W 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> New System ❑ Tank Replacement ❑ Repair <br /> Ll Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> X 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 ( Q <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 ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> �o($— 69 YO Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sew a a system shown on the attached plans. <br /> Na f P:fy�bar (Pjintl: Si MP/MP :SW No.: Phone Nu er. <br /> e d er � � � e_�d (7is) yQris <br /> Plumber's A ress: rName Des' ner: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signatur ssuing Age F e: od Date: ❑ Disapproved <br /> Y[ ❑ Owner Given Initial <br /> 11bApproved Adverse Determination <br /> Reps for Disapproval: <br /> Alternate courses)of Action Available: <br /> DILHR SBD6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />