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wsconsln APPLICATION FOR SANITARY PERMIT — <br /> ( IDILHR <br /> COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT # <br /> aEPRFTmEnT OF <br /> nIX15TRVLn00R&muminMLRT10n5 <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. al <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> T_)o,v N <br /> PROPERTY LOCATION <br /> V4ttAPE- <br /> ,5OV1/4 A110/4, S1,9, , T 4 N, R E (or TOWN OF: 5(2477' <br /> LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms.o)— ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 1K New System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF KT�HIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> �l 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 #_ A)A— 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: _7—/t <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 AREAABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> 10 1 / 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 (Print): Sign / MIFMPRSW No.: Phone Number: <br /> N komr 3o�a- 17/5) zvs< 3�s <br /> Plumber's Address: Narfie of Designer: <br /> / T 3 6o 7 O t�<Ji GtJj' �'3U - <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign re of Issuing Age tFan: ' Date: ❑ Disapproved <br /> ❑ Owner Given Initial <br /> J Approved Adverse Determination <br /> ason for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DILH R SBD 6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />