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APPLICATION FOR SANITARY PERMIT //� <br /> � �`� ���M�� COUNTY <br /> D 1 L H <br /> (PLB 67) UNIFORM SANITARY PERM( # <br /> -OEPfiRTi 1EnT OF / I� I (j <br /> - IfIWETR ALR00F6HUTTR FIELRTIOnS ( { a <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8'hxll inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> i z� ss T�,v� € ticw,t��n /yl�ssos <br /> PROPERTY LOCATION CITY: <br /> VILLAGE: <br /> 1/4Nw1/4, S / , T47QN, RI E (or W TOWN OF: ls« <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAR LAKE OR LANDMARK ATE I.D. NUMBER <br /> A— <br /> TYPE OF BUILDING OR USE SERVED /9_4 <br /> 1 or 2 Family Number of Bedrooms: L1 Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> El New System Tank Replacement ❑ Repair <br /> Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> LJ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> Seepage Bed El Seepage Trench LJ Seepage Pit EJ Holding Tank <br /> El Pit Privy <br /> El System-In-Fill ❑ In-Ground Pressure Ll Vault 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 S <br /> Lift Pump Tank/Siphon Chamber <br /> rIFTHIS <br /> ng Tank capacity <br /> facturer. 5 & <br /> IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground PressureTotal #of Prefab. Site Steel Fiberglass PlasticGallons Tanks Concrete Constructedc Tank Capacityump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feetl: PROPOSED (Square Feetl: <br /> 66 3 Private ❑ Joint ❑ Public <br /> 1,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na f Plumber (Print): Sign re: �+ MP/MPRSW No.: Phone Number: <br /> Z _ �3 07 (715- I z'1L/3527 <br /> L- - "PDi—t <br /> am of Designer: <br /> Plumber's Address: /}}��) ��,,11 �,v p <br /> 'C T D T' 7 o / ,g!?! /N/ 5 / Y A/ <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig ture of Issuing Agent: Fee: TD�7 ❑ Disapproved <br /> ,t / o-D /oI i J X ❑ Owner Given Initial <br /> nom,^ /iG' � / 5 Approved Adverse Determination <br /> eason for Disapproval: K J <br /> Alternate counsels)of Action Available: <br /> DILHR-SBD 639B (R. 5/62) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />