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wisconsio APPLICATION FOR_SANIT,ARY PERMIT <br />DILHR� COUNTY <br />(PLB 67) <br />TEnT F <br />UNIFORM SANITARY PERMIT # <br />DEPRRTO <br />InOUSTRV, LRBOR 6 HUMRn RELRTIons <br />C �rs6 3� <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 comDletina this aDDlication. PLEASE PRINT <br />PROPERTY OWNER <br />Floyd E. Wages <br />MAILING ADDRESS <br />422 S. 2nd Ave. Canton, IL 61520 <br />PROPERTY LOCATION <br />x5dTCY: <br />N2 1WA SE 1/4, S 36 , T41, N, R 17 *Xfr4 W <br />TOWN OFF: Swiss <br />LOT NUMBER <br />BLOCK NUMBER <br />SUBDIVISION NAME <br />NEAREST ROAD, LAKE OR LANDMARK <br />STATE PLAN I.D. NUMBER <br />15 <br />na <br />I <br />IBlack Bear Acres <br />St. Croix Trail and Cty "F" <br />I na <br />TYPE OF BUILDING OR USE SERVED <br />Lxl 1 or 2 Family Number of Bedrooms. 2 ❑ Public (Specify): <br />THIS PERMIT IS FOR A: <br />Y 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 />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 />415 <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 750 1 <br />Lift Pump Tank/Siphon Chamber <br />Holding Tank capacity <br />Manufacturer: TMC inc <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 />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 />2 <br />410 <br />415 <br />Sk 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): Sign tures MPXX9F4,MlXo.: Phone Number: <br />Donald Daniels 330 (715 463 2333 <br />Plumber's Address: e of Designer: <br />Nam <br />Box W Siren, WI 54872 same <br />COUNTY/ DEPARTMENT USE ONLY <br />Signature of Issuing Agent: <br />��"��iJ <br />w/idG✓� 6Q�Ge �� i <br />Fee: <br />°�, <br />Date: <br />/� _ �(/ <br />Approves <br />❑ Disapproved <br />❑ Owner Given Initial <br />Adverse Determination <br />ason for Disapproval: J <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 />