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APPLICATION FOR SANITARY PERMIT /' <br /> D'L H R (PLB 67) /����y6',✓ COUNTY <br /> U <br /> oeRRwrm¢nr oe UNIFORM SANI ARY PER T # <br /> mpusrwv.�weow s wumwn ws�wrwns <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 /> PR ERTY OWNER MAILING ADDRESS <br /> o r 42 & u 7 <br /> PROPERTY LOCATION 1=: <br /> .Ni!-tAti E: ` <br /> PC- 1/4 S E1/4, S.? T q , N, R IS- (or) W TOWN OF: S CtJ/ <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> IVA ,v A 6 z !rte <br /> TYPE OF BUILDING OR USE SERVED <br /> y� 1 or 2 Family Number of Bedrooms. T Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System Tank Replacement ❑ Repair <br /> LK Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> 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 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: G <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <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 Feetl: <br /> 3 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na a of Plumber (Print): Si e: MP/MPRSW No.: Phone Number: <br /> e e rl c /1 G �rh f 0� 7/s� 966 ,/is <br /> Plumber's Ad ess: Name f Designer: " <br /> w w� S Y�� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> K5— U" ��_�� ❑ Owner Given Initial <br /> �Approved Adverse Determination <br /> Re on 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 />