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SCO^=^ 'APPLICATION FOR SANITARY PERMIT <br /> D I L H R fur"e - COUNTY <br /> (PLB 67) UNIFORM SAN T ARY PERMI�# <br /> ^EPnPTTEIIT O µ <br /> PIWSTRV.LRBOR 6MUrtWn RELHT1Or15 <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Code for the system, on paper not less than 8Yzx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> ED ESSE L 3 <br /> PROPERTY LOCATION CITY: <br /> N W <br /> 1/4W1 14, S,10 , JR �I <br /> N, R Hef VIL TawagQE: cT[ Ove <br /> LOT NUMBER BLOCK NUMBBDIVISIN NAM ES ROAD, AKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> 0L > w _" <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 /> ❑ New System X 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 /> D<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 4o Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity X <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity /+" <br /> Manufacturer: W Q g CY CL <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 /> e�(Minutes per inch): REQUIRED (Square Feet): PROPOSE'D/(Square Feet): <br /> J ^3 —3 60 (oa 7 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for linstallation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Pri t) Sign ure: MP/MPRSW No.: Phone Number' <br /> N elS �cre <br /> Pluis Address: Name of Designer: // <br /> _ 7i �-2 LS �E C, <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> u _ p _ ❑ Owner Given Initial <br /> �saC /Approved Adverse Determination <br /> eason for Disapproval: Z yet <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />