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54O^51^ APPLICATION FOR SANITARY PERMIT <br /> � DILHR �rn�� COUNTY <br /> (PLB 67) <br /> OEPRRTmEnT os UNIFORM SANITARY PERMIT # <br /> snainnini In W5TRV.LRBOR6MUTRn FELRTIOnS <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. J I\ <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADmDf <br /> /11 C (Sc ��� <br /> PROPERTY LOCATION kan t17_,CITY:_ .Web, <br /> /4%id 1/4, S a l� , N, 1316-E- r W ILL PN oYI M 10 <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEARES ROAD LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> t�—tt <br /> l k WQ 1­3,r" <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: ❑ 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 /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity X 0100 <br /> 'f Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: W e IQ sieLCOX C 1, tP C_ <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 /> ^'p—T C//s 3 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 (Pr-nt): Sig ure: MP/MPRSW No.: Phone Number: <br /> (S �r per <br /> Plumber's Address: Name of Designer: <br /> w �(a f UcSc /UPAS o�� y- <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: El Disapproved <br /> ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> Ritfason for Disapproval: .�J <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 />