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APPLICATION FOR SANITARY PERMITDILHR (PL6 67) <br /> Urne OU <br /> NTY <br /> OF <br /> E <br /> FI..TgVLRBOg6FmqnqELRT10r5 UNIFORM SANITARY PE MIT#Z 79(,.29 /-4 J(s � <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Code for the system, on paper not less than 8Yzx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PR RTY OWN f/ MAILING ADDRESS �/p <br /> V( hF ec 'rfii r ►✓� t �C 0 wl S SA �oZ <br /> PROPERTY LOC CITY <br /> �q CITY: <br /> W1/4C 1n�/4, S � , Tu/, N, R W � NOF `e'it QY� <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAMEEST OAD LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> nhkFe w D" 8b© llb <br /> TYPE OF BUILDING OR USE SERVED Co"lcesS I&V% q'�h CI <br /> 1 or 2 Family Number of Bedrooms: TPublic (Specify): + fTJ6m S• <br /> THIS PERMIT IS FOR A: <br /> ;WNeW 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 /> 1 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 /> TotalI #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity I Soo <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: U.) 'es, Ct'-e ill <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 /> (Minut/es per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> T� (, Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for stallation of the private sewage system shown on the attached plans. <br /> Name of PI her (Print) Signa re: MP/MPRSW No.: phone Nutp¢�r: <br /> iqe <br /> plu er's Address: <br /> Name ofDesi ner: <br /> v l c�-e t /ld S vP t �� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa a of Issuing Ag t: Fee <br /> p: Date: / ❑ Disapprover) <br /> 3 -Ft` Approved Owner Given Initial <br /> Adverse Determination <br /> on 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 />