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APPLICATION FOR SANITARY PERMIT <br /> D I L H R (PL <br /> B 67) OUNTY <br /> oevnaTmenT or UNIFORM SA ITARY PERMIT# <br /> - n0USTRV,LR80R&HUmRnMLRT10n5 <br /> Z&.36iiLol <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8/zx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PRO ERTY OWNER MAILING ADDRESS Min! <br /> eejC r <br /> P OPERTY LOCATION �7 CITY: <br /> 1Y If /4 /4, S , TV N, R "94W VILLAGE: /] <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST R AD, LAKE OR LANDMMARK STATE PLAN I.D. NUMBER <br /> �. s�d_L ,��� <br /> TYPE OF BUILDING OR USE SERVED <br /> X1 or 2 Family Number of Bedrooms: + ❑ Public (Specify): ( . <br /> THIS PERMIT IS FOR A: <br /> A 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 /> ❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit Holding Tank <br /> ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy nPit Privy <br /> ❑ Existing, For Which A Previous Permit Is On File, Permit Of 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 capacityWL <br /> Manufacturer: Ad <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/$iphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inchl: REQUIRED (Square Fee!4 R POSED (Square Feet): <br /> NJ Y j 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): Si re_ ur MP/MPRSW No.: Phone Number: <br /> 4 <br /> Plumber's Address: Name of Designer: <br /> a / s4Ss- <br /> COUNTY/DEPARTMENT USE ONLY <br /> S- nature of Issuing Agent: Fee: Date: <br /> ❑ Disapproved <br /> ❑ Owner Given Initial <br /> 47Y(/,✓ / �/ 'as Approved gdverse Determination <br /> 'Reason 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 />