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=.,.eb�s,n APPLICATION FOR SANITARY PERMITHR OUNTY <br /> '��� ��► UNIFORM SANITARY PER.(v11T # <br /> 6 HUmnn RELRTiOna, of/63 /1 <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. (e <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> P PERTY OWNER MAILING ADDRESS <br /> oS3 Cl a 4 c r l7' 97 40 <br /> PROPERTY LOCATIONCITY: <br /> PE 1/4je 1/4, S T , N, R /rB (or) W <br /> VILLAGE <br /> N OF: SGr! l,J <br /> LOT NUMBER BLOCK N MBER SUBDIVISION NAME NSATTEST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> /U 44, 4 r &4 C_r,r..5 I -('4, e <br /> TYPE OF BUILDING OR USE SERVED <br /> Y 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 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 /> Dt 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 S <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: C <br /> IF THIS IS AN ALTERNATIVE SYSTEM( COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons C <br /> Tanks oncrete Constructed <br /> Septic Tk Capacity <br /> Lift Pump/anSiphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREAABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> a "7 t C) 1 1/-3 D— Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the rivate sewage system shown on the attached plans. <br /> Na a of Plumber (Print): Si e: MP/MPRSW No.: Phone Number: <br /> ad� r« � �tv1 � 0 QJ' 7/rP - 1 <br /> Plumber's AVress: Name of De gner: , <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa of Issuing Agent: Fee: Date: ❑ Disapproved <br /> ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> eason 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 />