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^_^ APPLICATION FOR SANITARY PERMIT <br /> E7-7 DILHRur" 1DOUNTV <br /> (PLB 67) UNIFORM SANITARY P MIT # <br /> oERRwnOUSTRV,LRBOR&HUl nQELRTIOnS -7117v2 //,13 <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 <br /> PR PERTY OWNED .`� MAILING'ADDRESS <br /> twila PROPER OCATION I/ pp CITLY: <br /> /4 f ��4, S N, F3 1 [[�(,gr �' VILLAGE: v1 re(.S <br /> LOTNUMBER BLOCK NUMBER SUBDIVISION NAME ESZT2AD, AKE OR LANDMARK STATE PLAAN� I.D. NUMBER <br /> �-� Z1 <br /> TYPE OF BUILDING OR USE SERVED <br /> W 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System Tank Replacement ❑ Repair <br /> 0 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 /> LJ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy <br /> Existing, For Which A Previous Permit Is On File, Permit #51P rf c x# //61 y issued /z -3- 7V <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 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: ipe f:-- <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 /> Private El Joint Ll Public <br /> I,the undersigned, hereby assume responsibility forstallation of t e private sewage system shown on the attached plans. <br /> It Of <br /> Name of Plymber (Pri tl: Signay MP/MPRSW No.: Phone Number: <br /> N S oma f' rill 2 17/T� <br /> Plumb 's Address: Na a of Signe <br /> 1e <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> ❑ Owner Given Initial <br /> LL-� GG G 1r1 JJ /Ot Approved Adverse Determination <br /> eason for Disapproval: �J <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 />