Laserfiche WebLink
� "'�`� � _" APPLICATION FOR SANITARY PERMIT X <br /> DILHR 2 ��A0"rr COUNTY <br /> eek OERRRTT,UR11 (PLB 67) UNIFORM SANITARY PERMIT # <br /> - InpLISTRV,LRBOR6HllmgngELRTIpnS <br /> L yo) <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Code for the system, on paper not less than 8Y,,x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> ✓/1/Y1,E5 57,o KL'f �/i < <br /> PROPERTLr �Y LOCATION r S <br /> /Vz�--1/4SC'1/4, S,� , T <br /> LOT WN OF 11A <br /> NUMBER BLOCK NUMBER S�UBDIVRISION�NAME w TO EAREST ROAD, LAKE OR LAN MARK STATE PLAN I.D. NUMBER <br /> - 'r <br /> TYPE OF BUILDING OR USE SERVED <br /> 14�"Ior 2 Family Number of Bedrooms. ;Z1 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 9J New 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 <br /> Ll System-In-Fill E] Holding Tank <br /> ❑ In-Ground Pressure ❑ Vault Privy El 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 <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity L--- <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: <br /> go <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 <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feetl: WATER SUPPLY: <br /> rI�TF�r"Ite ❑ Joint ❑ Public <br /> I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print): Signature: <br /> C�-�r� r t PoIP/MPRSW No.: Phone Number: <br /> Plumber's Address: 1./ �V � .�'1 . >5/t) <br /> Name of Designer. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: <br /> N�. ❑ Disapproved <br /> p r p ❑ Owner Given Initial <br /> / - a �aAPProved <br /> R on for Disapproval: t,/ Adverse Determination <br /> Alternate counsels)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, one Copy To; Bureau of Plumbing,Owner,Plumber <br />