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i` APPLICATION FOR SANITARY PERMIT <br /> �� DILHR <br /> -_J[i_ n1LC( COUNTY <br /> (PLB 67) <br /> � oewsRttnenr oc UNIFORM SANIjARY PERMIT# <br /> mews*nv,�neows Hurrwngecn,'nns1 C7 <br /> Axe/"/ I 40L/,12 ev'!; <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 /> iPPERTY OWNER MAILING ADDRFasS. <br /> T* r r s Sr 3S JO <br /> PROP RTY LOCATION �/ CITY: r, <br /> A)01 MSU-4/4, S , T YPN, R 7 F (or) (N J'TQWNOF1 <br /> LOT NUMBER I BLOC;XMBER I SUBDIVI I N�NAME RESIT ROAQ, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> P14 IV <br /> TYPE OF BUILDING OR USE SERVED ,i 11- I/!/ '!SJ <br /> 1 or 2 Family Number of Bedrooms. ❑ Public (Specify(: <br /> THIS PERMIT IS FOR A: <br /> ❑ New System ;R Tank Replacement ❑ Repair <br /> X Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> 54 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 d <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 Feet): PROPOSED (Square Feet): <br /> 3 y� O a~ Z Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewagEAsystem shown on the attached plans. <br /> N ef P oumber (Print): Si re: % . MP/MPRSW No.: Phone Number: <br /> a r wf o A- /�I K f <br /> Plumber'stdcls: Na of Designer: <br /> w� s � <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sin a of Issuing Agent- Fee: Date: <br /> Sig 9 9 M ❑ Disapproved <br /> A,— , - Ll Owner Given Initial <br /> Approved Adverse Determination <br /> Reason for Disappro <br /> Alternate course(s)of Action Available: <br /> DI LHR SBD6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />