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eiii0000i I APPLICATION FOR SANITARY PERMIT <br /> COUNTY <br /> �r D I L H R <br /> (PLB 67) UNIFORM SA <br /> lEnT OF 13 <br /> PERMIT <br /> a�OEPnRTrr <br /> InCLHsTRV,LR90R&HL1mRn RELRTIO - / , <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Code for the system, on paper not less than 81/zx 11 inches in size. / <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPZTY Ow ER /� MAU,LING ADDRESS / <br /> e- at. •'':S k3 P O W po P O >e Dq 41 f, <br /> PROPERTY LOCATION CITY: / <br /> NF-J1/4 SF_1/4, S II , TyQN, R /4 B(or) W T WNO Oofj[G� d <br /> LOT NUMBER BLOCK NyMBER SUBDIV`IS'ION NrE NEAREST ROAD, LAKE OR}ANDMARK STATE PLAN I.D. NUMBER <br /> 1 3 Al Nr <br /> 0♦ 4 4%A d .S �1Me S ICY vw S J!"0 a t/,''r_ <br /> TYPE OF BUILDING OR USE SERVED <br /> IA 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> D6 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 /> XT 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 Sail Conditions. <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity /a,U O X <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: (, <br /> 12 <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): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> yI is— 6 U r I V Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na�je of P/yiumber (Pry tl: Signature: MP/MPRSW No.: Phone Number: <br /> RQ Vew, c /l K/SLI W Gadd I//S) ��6'yir� <br /> Plumber's Address: FName of Designer: <br /> S91, ip <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig ure of Issuing Agent: Fee: C Date: ❑ Disapproved <br /> J ,� �O/ � 3��� Approved ❑ Owner Given Initial <br /> �77Adverse Determination <br /> eason for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DI LHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />