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I =coni^, APPLICATION FOR SANITARY PERMIT <br /> �y COUNTY� DILHR (PLB 67) UNIFORM SANITARY PERMIT# <br /> TlTOF <br /> nOU5TRV1PO6F1cJTR1RLnT10r15 <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 /> 7,pPE)'j OWNER MAILING ADDRESS <br /> /rfl1 /(5 11 o ►�-.. r S y" e vs an W i <br /> PROPERTY LOCATION CITY: <br /> SF 1/4/U41/4, S 3 , T yQN, R/7 F (or) WOWN OF) 0 <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EST RO LAKE LANDMARK STATE PLAN I.D. NUMBER <br /> 9 � � v / r ;rw Ts ,� � o a <br /> TYPE OF BUILDING OR USE SERVED <br /> IY 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> New System ❑ Tank Replacement ❑ Repair <br /> El Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> N1 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 Q0 V X <br /> Lift Pump Tank/Siphon Chamber 7 Ir <br /> Holding Tank capacity <br /> Manufacturer: uj C 00 <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 Site <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inchl: REQUIRED (Square Feet): PROPOSE,rD�(Square Feet): <br /> (V/S- b q b 9 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 lumber (Print): Sign re: MP/MPRSW No.: Phone Number: <br /> a de ric �a 1 e �oS lin 14W- <br /> Plumber's A reser Nam Desi ver: <br /> Lust !�e r mo i . .S' <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig ure of Issuing Agent: Fee: Date: ❑ Disapproved <br /> �� '� <br /> O Owner Given In <br /> y� " O Approved Adverse Determination <br /> eason for Disapproval: <br /> Alternate courses)of Action Available: <br /> DILH R-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing,Owner,Plumber <br />