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E7-7 -,scons:n APPLICATION FOR SANITARY PERMIT 5 ILHR ,'.GG?iY-tI - r.OUNTY <br /> men (PLB67) UNIFORM SANIT RY PERMIT # <br /> R4,LRBDRSHUMIRnRELRTons <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8Y x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNERi MAILING ADDRESS <br /> eoz n �lofMisOr✓ 1 lalsr04 Aad Alk ^9,r 14 Al. 55 <br /> PROPERTY LOCATION CITY: <br /> /U VILLAGE <br /> 1/4 E1/4, S , T YON, R / E (or) TOWN OF: ✓�P�`<l�B/`� <br /> LO 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: a� ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> V,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 /> ?1Seepage Bed El Trench Ll Pit EJ Tank <br /> 1 <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 O <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity , 't <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 /> / <br /> D Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nam of Plumber (Print): Signa re: MP/MPRSW No.: Phone Number: <br /> -77 TZ_ (7/3�13 <br /> Plumber's Address: t Na a of Designer: <br /> �r w/` s-Vyi� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig�ture of Issuing Agent: Fee: Date: <br /> / Disapproved <br /> d'V ❑ Owner Given Initial <br /> !!�✓'./ Approved Adverse Determination <br /> eason for Disapproval: <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 />