Laserfiche WebLink
reeeeeinei nAPPLICATION FOR SAN <br /> ITARY PERMIT <br /> EZIX � R � <br /> DiLHR (PLB 67) <br /> COUNTY <br /> UNIFORM SANITARY PER IT # <br /> 71/7/0 (/o;3/( <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 ERTY OWNER// MAILING ADOR SS <br /> I �! Y2 rS W ' 5 pr lv , <br /> PROPERTY LOCATION Or CITY: / <br /> A)F-1141VE114, S 3 , T37N, R 166 (or) W TOWN O A%l 'F f`' /2 C <br /> LOT NUMVER BLOCK NUMBER SUBDIVISION NAME EAR EST ROAD,�KE OR L$yN DMARK STATE PLAN I.D. NUMBER <br /> it/'AC O i.[T/ <br /> TYPE OF BUILDING OR USE SERVED <br /> X1 or 2 Family Number of Bedrooms: T Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System ❑ Tank Replacement ❑ Repair <br /> X Replacement Soil AbsorptionSystem ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> ,25 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 /> 7-� Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity , ,S/f 7 ej x <br /> Lift Pump Tank/Siphon Chamber Cr <br /> Holding Tank capacity <br /> Manufacturer: Le L <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #ofPrefab. 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 Feetl: PROPOSED (Square Feet): <br /> 6/5 Cf Private ❑ Joint ❑ Public <br /> 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na a of Plumber (PrinI): Sig ajt�u e: MP/MPRSW No.: Phone Number: <br /> C 'C i^/C 1 G �i R S ,i 1 �6+✓1- C� J� V 1 /,Sl '"�''eylS-7 <br /> Plumber's Add r ss: t NR of D signer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig ure of Is uing Agent: Fee:/ Date: ❑ Disapproved <br /> El Owner Given Initial <br /> L^� Approved Adverse Determination <br /> �qfson for isapp val: <br /> Alternate courses)of Action Available: <br /> DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />