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W15consin APPLICATION FOR SANITARY PERMIT /,o <br /> � D I L H R ��2hL" COUNTY <br /> (PLB 67) <br /> Tmemoc UNIFORM SANIT RY PERMIT # <br /> InDUS <br /> InOU5TR4,LRBOR 6 MUTRn RELRTIOnS <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Code for the system, on paper not less than 8%x i l inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> So <br /> PROPERTY LOCATION —1!7 T : <br /> A)"/4/V%Ah/4, S 0 , T y, N, R /s[ (or) W TOWN O S <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> 3 A C Bim, ti <br /> TYPE OF BUILDING OR USE SERVED <br /> IX 1 or 2 Family Number of Bedrooms: E Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> X 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 /> IjO Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdiny 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 'o 0 1 X <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 /> (Miinhnutes per inch): REQ//UIRED (Square Feet): PROPOOSEED/(SSqquare Feet): <br /> off- tP /-r (O `Y 6 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na of P umber (Print : Si MP/MPRSW No.: Phone Number: <br /> At IIori[ a tnt 6 GS'r/ <br /> lumber's Address:. , IF Na of esigner: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Is Agent: Fee: Date: <br /> ❑ Disapproved <br /> ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> eason for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DI LHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />