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w'Sc^^5'^ APPLICATION FOR SANITARY PERMIT <br /> � DILHR COUNTY <br /> (PLB 67) UNIFORM ANITARY PERMIT# <br /> ,anTpEPRRTT,LR1 OF <br /> Ir1IX15TRV�LRbOR 6MllmRII RELRTlOr15 j <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT 0*4 <br /> PR PEORT OWNER V r, rc, l`/ ,l, MAILING A,�DDRESS tq� (n p ok f <br /> PROPERTY LOCATION CITY: <br /> IUk71/4 VQ/4, S /0 , T1,, N, R yF- (or) W TOWN OF yS' <br /> LOT NUMBER BLOCK NUMBER SUBDIVI ION'NcAME ESTrr OAD, LAK�R L 4 DMARK STATE PLAN LD. NUMBER <br /> TYPEEl_OF BUILDING OO7R�CUSE SER((VEED ll X101 �/!+• <br /> 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <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 /> X 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 G <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: L <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'Sp <br /> hon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feetl: PROPOSE D (Square Feetl: <br /> / 0 1 T .3 ' )fl Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print): Sigpatyre: r / MP/MPRSW No.: Phone Number: <br /> Ro Jec b n f p S 7 <br /> Plumber's Add/ess:-7— Name of Designer: k <br /> yr f3 /tr Uj S <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si a ure of Iss . Agent: Fee: Date: ❑ Disapproved <br /> aU <br /> ❑ Owner Given Initial <br /> i> Approved Adverse Determination <br /> eason 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 />