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E <br /> APPLICATION FOR SANITARY PERMITf1 LDILHR RurMSANrOUNTV <br /> (PLB 67) UNIFORMSANIT RY PERM # <br /> as A enr oc <br /> . awowswurtwnras=arons q oto1 a(0 <br /> Code for the system, on paper not less than 8'/zxll'inches in size. <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> F�o z o S 1-vC-e 14 if-e PSf dawn 1 <br /> PROPERTY LOCATION11 W CITY: <br /> �+� VILL GE: /JI��K� <br /> 1/4 .�G1/4, S N. R �-{ef 'I 1 <br /> LOT NUMBER BLOCK N MBER SUBDIVISION NAME ARES OAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> 04 d <br /> TYPE OF BUILDING OR USE SERVED <br /> )I 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System Tank Replacement ❑ Repair <br /> 7C Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> 44 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 B <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: w Aj <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 /> (Minutes per inch) REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> Q Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for i r1stallation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Pint : Signat MP/MPRS No.: Phone Numb rr p. �. <br /> Koe' 'PY H1la PoW 7/ 6?0q <br /> umber's Address: Name of Designer: <br /> c s ���3 ie�S r— <br /> COUNTY/DEPARTMENT USE ONLY <br /> Pson <br /> Issuing Ag Fee' Date: �Disapproved�Initial <br /> Ap��L] <br /> rmination <br /> isapproval <br /> Alternate courses)of Action Available: <br /> DILHR-SBO-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />