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E7-7]7 <br /> s�^ APPLICATION FOR SANITARY PERMITILHR OUNTV <br /> (PLB 67) UNIFORM SANITARY PERMIT# <br /> enT oeVLRBOR&HUTRnMLRTJOoS D/L13 <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, 11YQ(O <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROP R Y OWNER 11 MAILING ADDRESS <br /> < •� � ireYV WI <br /> PROPERTYt1_0 ATION CITY: <br /> Go"1/4 `1/4. S 23 . T VJJ, R /6 g (or) W 0 r/ h <br /> LOT NUMBER BLOCK N}19ER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED ,11 vJ)\ �C/J1 /h <br /> Lr 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 29New System ❑ Tank Replacement ❑ 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-FiII ❑ 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: ��-- <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 AREAABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> 3 / to Y Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Napq of qIumber.(Print): S' not e: ,� MP/MPRSW No.: Phone Number: <br /> Plumber's Add r s V Na De ig er: <br /> q FP <br /> 41 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig lure of Issuing Agent: Fee: Date <br /> DaKte: f ❑ Disapproved <br /> IV 1�L,7�Kkt /� y 1lJ .(QOL'S� d —/— ��" Approved ❑ Adver Given Initial <br /> Adverse Determination <br /> eason for Disapproval: F✓ <br /> Alternate courses)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber //��� <br />