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w ^^=^ APPLICATION FOR SANITARY PERMIT <br /> [ (�� DILHR f <br /> tS'LL�x- `f_"T`f COUNTY <br /> (PLB 67) UNIFORM 3ANITARY PERMIT # <br /> �OERRRTTEnT OF <br /> McIUSTRV,LREIO 6 HUTRn RELHTIOnS / / l <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 n size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> eT- / G•t� u -q WI <br /> PRO ERTY,LOCATION _ CITY: T <br /> 6001V4 a- o 1/4, S 3_, T%Q N, R /6V (or) W TOWN OF' •/ C <br /> LOT UMBER BLOCK SUBDIVISION NAME REST ROAD, LAKE OR LANDMARK STA E PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> ;X1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> X New System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modi ication <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdi iy Tank <br /> ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Pr vy <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 Filierglass Plastic <br /> Septic Tank Capacity Q Q <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer- A4 C_ <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site Steel F erglass Plastic <br /> Gallons Tanks Concrete I 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): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> dp/S 1 6 el F I X Private ❑ Joint Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached pla s. <br /> Na f P tuber (Print): MP/MPRSW No.: hone Number: <br /> n r✓ t1 H C 6 tl r/ 7,05 <br /> Plumber's 1� ress:-7� Na of Designer:Ltl`Q� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signatur of Issuing Agent: dee: J Date: ❑ D sapproved <br /> /'(//ALy ❑ O ner Given Initial <br /> Approved A verse Determination <br /> �iiWion for Disapproval: <br /> Alternate counsels)of Action Available: <br /> DILHR-SBD-6398 IF,5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />