Laserfiche WebLink
APPLICATION FOR SANITARY PERMIT <br /> DILHR �r�r��� COUNTY <br /> pEPRRTn1EnT OF (PLB 67) UNIFORM SANITARY PERMIT # <br /> InnUSTRV,LABOR&HUmAn RELRTIOr15 .796,27 \ <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8Y x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILINGADDRESS <br /> JPe II �UC <br /> Eo , <br /> b'S <br /> LOCATIONITY: <br /> I UI 1/41iX, 1/4, s3.-)- , Turi N, R l(0 E [o<0 V N OE 66 <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME AREST ROAD AK R LANDMARK STATE PLAN I.D. NUMBER <br /> D nd Add. IC15 ye(& <br /> TYPE OF BUILDING OR USE SERVED <br /> X 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> V 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 /> k 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 0 <br /> Lift Pump Tank/Siphon Chamber ing p <br /> Holding Tank capacity <br /> Manufacturer: Q vh C Al c <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 /> --- —_ J 1 I P< 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 (Pri t): Signa ure:" � MP/MPRSW No.: Phone Number: <br /> N-eIS oar f— /I,�y—� /-9PS-7 7"S 9 6 <br /> MPlu ber's Address: Name Or signer: <br /> �� '2— W Wis l " vim. �N <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa ure of Issuin Agent: Fee: Date: ❑ Disapproved <br /> ❑ Owner Given Initial <br /> Approved <br /> Adverse Determination <br /> son for Disapproval: <br /> Alternate courselsI of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />