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5CO^51^ APPLICATION FOR SANITARY PERMIT <br /> DILHR <br /> .' /'-• ' COUNTY <br /> (PLB 67) UNJFORM SAN( ARY PERMIT,# <br /> [77 Er1T OFDU5TRV,LRBOR&HUrrRn RELRTions <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 /> PRO TY OWNER MA Li IN <br /> PROPERTO LOCATION CITY: ') <br /> 1/4 1/4, S T , N, R E (or) W VOWN GE: <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME E.SST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> C / A4 A <br /> TYrPE, OF BUILDING OR USE SERVED <br /> -� <br /> LL] 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System ❑ Tank Replacement ❑ Repair <br /> EP'Neplacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTE�VI COMPLETE THIS BLOCK. <br /> El 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 <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: J <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): nPROPOSED (Square Feet): ,�-,,- <br /> - ► �-- l 950 150 _ „ .� l� Private ❑ Joint ❑ Public <br /> 1,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name f Plumber (P I: Signatur r) MP/MP RSW No.: Phone Number: <br /> L"A _ �7Pa�T2q�;� �v4 )X99 <br /> Plumber's Address: S Name of Designer: <br /> /3r7c r/e� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signat f IssuiZAn, Fee: Date: Ll Disapproved <br /> ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> on for Disappr val: <br /> Alternate counsels)of Action Available: <br /> DILHR SBD-6398 (R.5/62) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />