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APPLICATION FOR SANITARY PERMIT <br /> E 1 L HR �O�.»N COUNTY <br /> (PLB 67) <br /> UNIFORMSANTARYPER IV,LRBOR&HUTRnR LRT.,,. <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT 3.3 <br /> PROPERTY OWNER — MAILING ADDRESS, <br /> e r inson 6P/S' ?// aj r V /f", .T <br /> PROPERTY LOCATION CITY: <br /> SW1/4.TE1/4, S 7 T Q N, R / ff (or) W KOWN OF. SG 0 <br /> LOTNUMBER BLOCK NUMBER SUBDIVISION NAME ST ROAD, LAKE OR LAND ARK STATE PLAN I.D. NUMBER <br /> VA <br /> TYPE OF BUILDING OR USE SERVED <br /> X 1 or 2 Family Number of Bedrooms: CL ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> F4 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 /> R Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdiny 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 /e1. 0 O <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 AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRE,DD (Square Feetl: PROPOSES D/ (Square Feet): <br /> 3 i/ / QSqJX Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N e of lumber (Print : Si ure: MP/MPRSW No.: Phone Number: <br /> a o /1 ios e � 03 6S -21,v6t <br /> Plumber's dress Name n Name of Designer: <br /> W P $ !Z r— �A1 r d �K 1 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa a of Issuing ent: Fee: Date: ❑ Disapproved <br /> i`jApproved El Owner Given Initial <br /> J D/✓ Adverse Determination <br /> ffin for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />