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D^51^ APPLICATION FOR SANITARY PERMIT <br /> I L H R (PLB 67) COUNTY <br /> DEPRRTRIEnTO UNIFORM SANITARY PERM T# <br /> In01USTRV,LR130R&muR nMLRTiDrn% 79 /�G D <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 /> PROPERTY 9WNER 1 r MAILING ADD ESS <br /> 4 ?,tj z-e C. h I w ie 6.s /- w; <br /> PROPERTY40CATION CITY: <br /> S U 1/4 N E1/4, S 3 TQwN <br /> , T YUN, R /�o R (or) W OF: Q 17 cl <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> IvA Nk U ,D-e ,CX 4c/T-t- <br /> TYPE OF BUILDING OR USE SERVED <br /> 29 1 or 2 Family Number of Bedrooms: Tj Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> X New System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> LJ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> Y9 Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑i Holding Tank <br /> ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑i 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 0 U d X <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: 0- <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <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 Feetl: <br /> S I 6 y f X Private ❑ Joint ❑ Public <br /> 1,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> NapP�e of lumber (Print Sign MP/MPRSW o.: Phone Number: <br /> (Cv erIC t30 x 6 ©X D/XIfk4-411 S? <br /> Plumber's A dress VName of Designer: , <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing A ent: I Fee: Date: <br /> Disapproved <br /> `r <br /> ❑ Owner Given Initial <br /> p+ <br /> 7—If—P4 APProved Adverse Determination <br /> ason for Disapproval K✓ <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 />