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APPLICATION FOR SANITARY PERMIT <br /> DILHR <br /> /L 1L'-�I�i � � COUNTV <br /> (PLB 67) <br /> M0USTt LR130G UNIFORM SANITARY PERMIT# <br /> - InWSTRV,LnBOR6MUTPngELHTIOnS <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8Yzx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTYq�' ER MAILING ADDRESS / <br /> 1)dn ( aK ti rte. � /16 1{l ��fUiruJ d V ew f w>^ h <br /> PROPERTY LOCATION CITY: <br /> VE1/4SW1/4, S a7, T V, N, R /6E (or) W "0 NOF) Sw <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAMEREST ROAD, LAKE OR LANDMMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> Y 1 or 2 Family Number of Bedrooms: -F Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> IV 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 /> 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 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: LAIJ G IQ <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 Feetl: PROPOSED (Square Feetl: <br /> Y1 (U 4/3 . I C50 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na of PI tuber (Print): Sy�y�re: MP/MPRSW No.: Phone Number: <br /> t�Q �r1� k Y Irn r 6 6,?d 7ir1�66 Sri <br /> Plumber's AgdresT: �+ r� �j Nar�tg of Designer: N <br /> W `i- s 7Y1 `oi sr SZ 7 v� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa of Issuing gent: Fee: Date: <br /> n ❑ Disapproved <br /> ElOwner Given Initial <br /> Approved <br /> 0 Adverse Determination <br /> ason for Disapproval:/ <br /> Alternate courses)of Action Available: <br /> DILHR-SBO-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />