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r D i L H R APPLICATION FOR SANITARY PERMIT <br /> A_ '"^'bOUNTV <br /> _ (PLB 67) <br /> UNIFORM SANITARY PER T# <br /> S„� 76o3 (l1y38� <br /> —Attach complete plans in accord with s. H 63,05,Wis. Adm. Code for the system,on paper not less than B''/:x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PR ERTV OWNER MAILINGADDRESS <br /> her A I�C < /� sr �GJ7wr <br /> PROPERTY LOCATION M CITY: <br /> X'LJ1/4NEI/4, Say, T 'VON, RYCII (or) W YIwNOF: J4c i130r1 <br /> LOT NUMBER BLO;K,NKMBER SUBDIVISION NAME ST ROZ, LAKE OOR L7MARK STATE PLAN I.D.NUMBER <br /> j TYPE OF BUILDING OR USE SERVE/tDV//AC' <br /> w// <br /> •Y 1 or 2 Family Number of Bedrooms: ❑ Public 'Specify): <br /> THIS PERMIT IS FOR A: <br /> 9 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 /> 21 Seepaye 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 /> Tocol Pot Pretab. Sue Seel Flberglgss Plastic <br /> Gallons Tanks Conrete Cum, curd <br /> Septic Tank CtwacoY ,S )`c <br /> Lift Pump TanklSne,o Chamber <br /> Holding Tank cauxen, <br /> Manufacturer: WC, <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Tocol #of PConcretrefab.e Site 5'e" FIDer9lass Plastic <br /> ons Tanks Consaruned <br /> Scenicc Tank Capacity Gall <br /> Lift Pump/Siphon Chamber <br /> Marmhemrec <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): R EO(U'IRED (Square Feell: PROPOSED ISyume Feetl: <br /> '137 � '� 1 (Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N pl lumbar (Printf: Sign ¢: MP/MPRSW No.: Phane Number: <br /> 4 V F Mc r tl � •hS li�, C)3JS 17is)��6 <br /> Plumber's Addre,, Na f De Igner. <br /> w r ✓ '7 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signatureof Issuing Ag,¢i�t'. Fee: Dat¢I ❑ Disapproved <br /> L7. reh Given mi.ial <br /> /l2e G o 0 CO b O ) pr <br /> Apoeatl Aa a se >termination <br /> axon for Disapproval: pY <br /> Aherne,,ccursels)of Action Available: <br /> DILHR 59063981 R.5/87) DISTRIBUTION: Original to County, One Copy Tse Bureau of Plumbing,Owner,Plumber <br />