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^=^ - APPLICATION FOR SANITARY PERMIT <br /> EZ : I L H R � COUNTY <br /> (PLB 67) ` UNIFORM SANITARY PERMITT # <br /> RTTEnT dL 11TRV LR00R6ML1TFn RELRTlOr15 Z l 73 % <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 OWNER MAILING ADDRESS / y— <br /> I- to R T" w •e ti f rIt <br /> P OPERTY LOCATIO CITY: <br /> PO 1/4 SE1/4, S a , Tit N, R &IV(or) W &VI <br /> WNOF OG�� 4n <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME REST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER A"A <br /> PA V1 S Z4 r <br /> TYPE OF BUILDING OR USE SERVED <br /> 9 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System ❑ Tank Replacement ❑ Repair <br /> W 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 _—e, �/S/ ' R• 7 O <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: G Ogg <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 ISquare Feet): <br /> 8 y/ 0 y 0 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 Plu ber (Print): Sign�Lure: MP/MPRSW No.: Phone Number: <br /> u c�e e .� vC <br /> Plumber'sAddress: <br /> �Address: <br /> Na a of D signer. <br /> VAL1J"rl d.i <br /> COUNTY/DEPARTMENT USE ONLY <br /> S;igo of Issuing nt: Fee: Date: ❑ Disapproved <br /> ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> son for Dis proval: <br /> Alternate course(s)of Action Available: <br /> DILHR-SBE)-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />