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� D I L H R APPLICATION FOR SANITARY PERMIT <br /> COUNTY <br /> oeRwwTmenT oe (PLB 67) UNIFORM SANITARY P RMIT # <br /> In0USTAVLR90R&HLImRn.LRTX . 79676 /a5 73 <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 / / / S-0 <br /> OFr^ rr // �SLt 4bn 6F d <br /> PROPERTY CATION CITY: <br /> ,3'G11/4Sw1/4, S �3 J4/0N, R/ .E (or) VV VI WN OF <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME AREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> /� ,v,4 Al ,4 B@ s s 4 _ <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 oN<y ❑ 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 /> ❑ 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 �,s <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 <br /> #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 /> Private L:1 Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na of Plp tuber (Print �j Sig re: MP/MPRSW No.: Phone Number: <br /> �CTd �cric ,J � <br /> Plumber's <br /> n^IrCe's7.r r -t ' Namgof Designer: <br /> Uy L <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa a of Issuing W <br /> t: Fee: 0.) Date: ❑ Disapproved <br /> ft�� /i ��j ❑ Owner Given Initial <br /> �✓ 1 Y Approved Adverse Determination <br /> "pMon for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DI LHRSBD6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />