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APPLICATION FOR SANITARY PERMIT <br /> D J L H � b -✓I-[�- r'OUNTY <br /> (PLB 67) UNIFORM SAN TARY PERM T <br /> IIVVS <br /> ITRW. # <br /> o OUS T LR of BOR6MVTR1l RE1R1­10n5 / / -3 <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 OWMAILING ADDRESS �t �/ / <br /> O ,- QNE/ji /7 S �'1 SPI^ i / /J e T /f r d o <br /> PROPERTY LOCATION CITY: <br /> $ ( /4 Si£1/4, S T . N, R / lor) W OWN GE: -Y W/S <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> Pk I N n/ c{ Mrk �erva F/ou <br /> TYPE OF BUILDING OR USE SERVED <br /> y 1 or 2 Family Number of Bedrooms. ❑ Public Specify): <br /> THIS PERMIT IS FOR A: <br /> X New System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision i ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> >OSeepaye 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 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: 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 I ABSORPON AREA ABSORPTION ARA WATER SUPPLY: <br /> (Minutes per inch): RETIQUIRED (Square Feet): �PRROPPOSED (Square IEatl: <br /> �1 Q 7 S [Y Private ❑ Joint ❑ Public <br /> 1,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na a of Plumber (Print): Sign tore: MP/MPRSW No.: Phone Number: <br /> Iz <br /> Plumber's Address: IF Nama„gf Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa of Issuing ant: ` J Date: ❑ Disapproved <br /> / ❑ Owner Given Initial <br /> 'ems DV✓ Approved Adverse Determination <br /> R on or Dis pprovay <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 />