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in APPLICATION FOR SANITARY PERMIT <br /> E: �: <br /> I L H R �+FT� BOUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT# <br /> TEI'lT OF'EnT OR 6MUTRr1RELliTKlr15 J/5/ 7C (/`/9'3) <br /> -Attach complete plans in accord with s. H 63.05,Wis.Adm. Code for the system,on paper not less than 8Yzx 111 inches in size. / <br /> -See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS /,16t ' RA.RfeeA C;4cLr <br /> FAMD41YA" Orr u r14 <br /> PROPERTY LOCATION -6i•W7 9- <br /> b4istR8 E- <br /> /0 <br /> : r n�17- <br /> GJ1/4*r1/4, S TiU, N, R/ EMM W TOWN OF: J <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D.NUMBER <br /> / (Zo A4 E <br /> TYPE OF BUILDING OR USE SERVED <br /> Z+-'rr 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> (mew 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 /> A 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 <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 <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <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 /> /O Tf'U L�rivate ❑ 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): Signature: MP/MPRSW No.: Phone Number: <br /> EG:`A XC i`A A6E c?o4d s'-1 4lC' <br /> Plumber's Address: Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> ❑ Owner Given Initial <br /> QjjK/,O O O( � Approved Adverse Determination <br /> Rtison for Disapproval: 0 KJ <br /> Alternate course(s)of Action Available: <br /> DILHR-SBO-6398(R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />