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wlsconsin APPLICATION FOR SANITARY PERMIT <br />* � PLB 67 COUNTY <br />DILHR <br />- DEPRRTTErITOF ` ) UNIFORM SANITARY PERMIT # <br />- InOUSTRY,LRElOR6HUTRrI RELRTIOnS <br />�� 7 97 (iiS.29 <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 comoletinp this application. PLEASE PRINT <br />PR FORTY OWNER, <br />y"' / i c§ `A <br />MAILING XDRESS <br />D(�n LQ <br />PROPERTY LOCATION <br />CITY: <br />W1/4 SE1/4, S off- , T Z/ON, R / 0 (o0 W <br />F <br />LOT NUMBER <br />BLOCK NUMBER <br />SUBDIVISION NAME <br />FNAREST ROAD, LAKE OR LANDMARK <br />STATE PLAN I.D. NUMBER <br />❑ Pit Privy <br />�A <br />Al& <br />e C C le C1 <br />T' v q FL <br />FYPE OF BUILDING OR USE SERVED <br />1 or 2 Family Number of Bedrooms: Public (Specify): L- �cc <br />"HIS PERMIT IS FOR A: <br />❑ New System 5e 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 />ABSORPTION AREA <br />ABSORPTION AREA <br />WATER SUPPLY: <br />Seepage Bed ❑ Seepage Trench <br />❑ Seepage Pit <br />PROPOSED (Square Feet): <br />❑ Holding Tank <br />System -In -Fill ❑ In -Ground Pressure <br />❑ Vault Privy <br />❑ Pit Privy <br />❑ Existing, For Which A Previous Permit Is On File, Permit # <br />issued <br />❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. <br />Total # of <br />Gallons Tanks <br />Prefab. <br />Concrete <br />Site <br />Constructed <br />Steel Fiberglass Plastic <br />Septic Tank Capacity <br />Lift Pump Tank/Siphon Chamber <br />Holding Tank capacity <br />Manufacturer: rJ.J C <br />IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: <br />❑ Mound <br />❑ In -Ground Pressure <br />Total #of <br />Prefab. <br />Site <br />Steel Fiberglass Plastic <br />Gallons Tanks <br />Concrete <br />Constructed <br />Septic Tank Capacity <br />Lift Pump/Siphon Chamber <br />Eq <br />Manufacturer: <br />PERCOLATION RATE <br />ABSORPTION AREA <br />ABSORPTION AREA <br />WATER SUPPLY: <br />(Minutes per inch): <br />REQUIRED (Square Feet): <br />PROPOSED (Square Feet): <br />Alternate course(s) of Action Available: <br />C' <br />❑ Private Joint ❑ Public <br />, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br />Ja f Plumber (P,rint):Si u MP/MPRSW No.: Phone Number: <br />'umber's Ad ress: Nine if,�Design <br />COUNTY/ DEPARTMENT USE ONLY <br />Signature of Issuing Agent: <br />Fee: <br />Date: <br />7'-�/-IPy <br />A roved <br />pp <br />❑ Disapproved <br />❑ Owner Given Initial <br />Adverse Determination <br />ason 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 />