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5=0 =In APPLICATION FOR SANITARY <br /> PERMIT � zl <br /> -COUNTY <br /> B 67) UNIFORM SANITARY PERMIT # <br /> WrIT OF <br /> � / y1 <br /> - Ir1IX15TFV,LWBOP6Nl1RKir1FlELHTIpr15 <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 /> PROPERTY OWNER MAILING ADDRESS <br /> w O <br /> PROPERTY LOCATION '/ ` VWcL-A5 <br /> l!O 1/4 1/4, $ 'f . T 6i N, R/ -&(or) TOWN OF: S C O <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> *1 or 2 Family Number of Bedrooms: � ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> IX 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 /> X Seepage Bed ❑ Seepage Trench ❑ Seepage Pit F-1 Holding Tank <br /> LlSystem-In-Fill L-1In-GroundPressure ❑ 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: 'r w R <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 [WT7ERSUPPLY(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> S- /d [1v ivate ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na f Plumber (Print): / Signature: MP/MFRSWY No.: Phone Number: <br /> Vi 7��OS (7i�1YL4- Z1ZQ3 <br /> Plumber's Address: V <br /> Name of Designer: <br /> COU /DEPARTMENT USE ONLY <br /> Signet f Issuing Agent: Fee Date: ❑ Disapproved <br /> �J/ �`✓ ` 6�r I� Owner Given Initial <br /> � J O J pproved Adverse Determination <br /> 15Wn for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DILHR SBO6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />