Laserfiche WebLink
ED�5TR�LRB <br /> sinAPPLICATION FOR SANITARY PERMITILHR COUNTY <br /> (PLB 67)ooUNIFORM SANJTARY PER IT # <br /> owswumwnwecwrians <br /> �Z/7Gza <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Code for the system, on paper not less than 81/zx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPEg7Y OWNER MAILING ADDRESS _ <br /> C1 <br /> '41 1— s's Q .o��'s4.2 <br /> PROPER LOCATFON CITY: <br /> I1/ 1/4, S-;2�, T , R E JOr T NOF: c'c <br /> LOT NUM BLOC NfJMBER SUBDIVISION NAME EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms. :Ej Public (Specify): <br /> THIS PERMIT IS FOR A: « /r2 FZ <br /> ❑ 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 /> Septic Tank Capacity Gallons Tanks Concrete Constructed <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer. :LSio! y e - `/ <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 WAFER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nameof umber (Print): I Signs t MP/MPRSW No.: Phone Number: <br /> � F r � ✓�� Z� . / y�iyTu��(c <br /> Plu d ess-. .� Name of esigner: .� <br /> 44 Z-2 <br /> COUNTY/DEPARTMENT USE ONL <br /> Signature of Issuing Agent: Fee: OU Date: <br /> El Disapproved <br /> ❑ Owner Given Initial <br /> u'//' ' - ✓ y Approved Adverse Determination <br /> ason for Disapproval: KI <br /> Alternate course(s)of Action Available: <br /> DILH R Sao 6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />