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wei APPLICATION FOR SANITARY PERMIT <br /> ' DILHR <br /> COUNTY <br /> (PLB 67) UNIFORM SANITARY PER IT # <br /> OEPRRTTErIT OF <br /> InOLISTRV LnBOR 6 MrIRIRrI gELPT1On5 / O/�O / n D/ <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8/x I I inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> 84y-I X4 FFV 1/A/�r_ S u 2 Z S'/ (/ 4 /—ort/ Lf4ke WD 57— P)401 A/tvrz' <br /> PROPERTY LOCATION CITY: <br /> VILLAGE: <br /> w 1/4 F_ 1/4, S 13 T3?, N, R II (or) W TOWN OF: V <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 /> 3j] 1 or 2 Family Number of Bedrooms. a ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> L' 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 ❑ 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 p t`— <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): REQUIRED (Square Feetl: PROPOSED (Square Feet1: <br /> 3 [X Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print): Signete: MP/MPRSW No.: Phone Number:7i� <br /> u l w / (&'35) aUF7 <br /> Plumber's ddress: Name of Designer: <br /> / 3 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signaf�uq of Issuing Agent: Fee: Date: ❑ Disapproved <br /> e a El Owner Given Initial <br /> Approved AdverseDetermination <br /> Posen for Disapproval: <br /> Alternate course(s)of Action Available: <br /> Di LH R-Sa D 6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />