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E <br /> ^_^ APPLICATION FOR SANITARY PERMITILHR COUNTY <br /> (PLB67) UNIFORM SANITARY PERMIT # <br /> . Aa�s mA^ E a.p^= 796 7.? (/ <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 OWNER MAI II NN.G ADDRESS <br /> 44 rs- I C.J•r. <br /> PROPERTY LOCATION I I CITY: <br /> / 'W1/4/U�1/4, S J , T N, R GE: <br /> F� Q, ��� (Of) W TOWN 2 h <br /> LO;NU{v1BER 13LO K NXMBER SUBDIVISION NAME EA EST ROAD, LAKE OR L NDMARK STATE PLAN I.D. NUMBER <br /> /v'11L /t� A �ce4 <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms. Z ❑ 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 /> -y—. Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity /r/ y. S'V X <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: 1. <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <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 /> S V/ d 1 4P S/ 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 lumbq (Print): Sign ture: MP/MPRSW No.: Phone Number: <br /> R0 ntc O 0S r/ 1 (7/s, <br /> Plumber VNa a of Designer: <br /> r—� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sre of Issu' Ag Fee: Date: <br /> ,Q t p Disapproved <br /> (/�� /—.2 —a 6 A roved ❑ Owner Given Initial <br /> PP Adverse Determination <br /> �ffason for Disapproval: <br /> Alternate courses)of Action Available: <br /> DILHR S60 6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />