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77 APPLICATION FOR SANITARY PERMIT <br /> COUNTY <br /> D I L H R <br /> 'E^T (PLB 67) <br /> ^ous.n.., Aer,A s.. ^s�cn.ons UNIFORM SANITARY PERM T # <br /> 5, 8,2 3 ( l15iT7 <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 RTY OWNER MAILING_ADDRESS <br /> /-/Wii, 1es KvoA/ LW/1 112 Ien/10 - c,/1 Sy8'0 / <br /> PROPERTY LOCATION CITY: C <br /> 'v 1/4 Alta-1/4, S / T39 N, R /9 B (or) W VILLAGEL44N OE: <br /> / 1 / <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> AI 1 or 2 Family Number of Bedrooms. ❑ Public (Specify(: <br /> THIS PERMIT IS FOR A: <br /> ❑ New System [ Tank Replacement ❑ Repair <br /> X 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 /> 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 - <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: <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 /> S//O <br /> `11 C> 18l Private ❑ Joint ❑ Public <br /> 1,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Pri <br /> innt <br /> t)): Signature MP/MPRSW No.: Phone Number: <br /> ITu LJ f /Son/ 4l ` "-"--�"'-'� 4V C// '� (C3�r- -2 4�7 <br /> Plumber's,Address: Name of Designer: <br /> a / <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signatur of Issuing Agent: Fee: Date: <br /> ❑ Disapproved <br /> 9.5-"60 /} eta Yc ElOwner Given Initial <br /> ✓ dg- / Y Approved I Adverse Determination <br /> son for Disapproval: <br /> Alternate counsels)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing,Owner,Plumber <br />