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APPLICATION FOR SANITARY PERMIT <br /> [7- <br /> DILHR COUNTY <br /> (PLB 67) UNIFORM SANITARY PER IT# <br /> OEPiNiTnlEnT OF <br /> I^OUSTRV,LBBOR 6.MUMFn PELRTbnsa60136 ( 11773 <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Code for the system, on paper not less than 8Y2x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS o � <br /> L-e / O �/ �� / 7a- Let? e ,/p V` J"/— n 66 <br /> PROPERTY LOCATION CITY: <br /> v 1/4-qIll 1/4, S 2-0 , T-16� N, R/ E (or) W VILLAGE:JQWN OF se,fir <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: o� ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System ❑ Tank Replacement ❑ Repair <br /> IX Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> k1 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 "75 D It <br /> Lift Pump Tank/Siphon Chamber DO l <br /> Holding Tank capacity <br /> Manufacturer: GaJ 2 ¢ e V C O e-7- <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 AREAABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feetl: PROPOSED (Square Feet): <br /> -73 Y /v L./ ) I R Private ❑ Joint ❑ Public <br /> 1,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print): Signatur MP/MPRSW No.: Phone Number: <br /> �--� W v Soi✓ t,�/ v S/4/ 0 t7f 5'—) &3i —dc( 7 <br /> Plumber's A ress: Name of Designer: <br /> 3 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signet re of Issuing Agent: Fee: Date: ❑ Disapproved <br /> 60 ElOwner Given Initial <br /> i v%Opp S Approved Adverse Determination <br /> ason for Disapproval: <br /> Alternate courses)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />