Laserfiche WebLink
APPLICATION FOR SANITARY PERMIT <br /> COUNTYDILHR (PLB 67) UNIFORM SANITARY <br /> PERMIT# <br /> OEPWiTnOF <br /> IIIl <br /> OUSTRV.LFLRBOR UTRr1RELRTIOr15 <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 PERTY OWNER MAILING ADDRESS ¢ <br /> R. <br /> PROPERTY LOCATION CITY: <br /> X1/45 X814, S TYON, R T6@ (or) W TOWN V74 an <br /> LOT NUMBER I BLOCK 7y} VI MBER SUBDIO NAME / AREST ROAD, LAK OR LANDMARK STATE PLAN I.D. NUMBER <br /> S-- lY � luprrr�d c. ��c,: <br /> TYPE OF BUILDING OR USE SERVED <br /> 'L 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): <br /> THIPERMIT IS FOR A: <br /> %New System ❑ Tank Replacement E] Repair <br /> ❑ Replacement Sail Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> N6 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 /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity S <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 /> ? y t d / 3 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nme of gglumber (Print): Signa nn � � MP/MPRSW No.: Phone Number: <br /> o d r, d �c� rc7fi 6. c 3 9 s ) x'66 y <br /> lumber's Ad(fess: rNa f Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa re of Issuin Age t' Fee: Date: ❑ Disapproved <br /> ` ` !� ❑ Owner Given Initial <br /> �� � � ✓ p� Approved Adverse Determination <br /> ason for Disapproval: <br /> Alternate courses)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />