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APPLICATION FOR SANITARY PERMIT <br /> � DILHR 1J COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMI # <br /> aaaaa� DEPRRTTEnT flF �1 9/�(i^ _ <br /> r1IX STRV,LRBOR6HUmRn1 LRTIOr15 1 / v 2 � /� <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8'/x 11 inches in size. U Ip <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> C P Oa ^A ST Cale 3� <br /> PROPERTY LOCATION CITY: s / 7--� <br /> SWr/4ML`t/4. S �, T3 N, R �7 W VI GE: 'yo & <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ARES OA LA E OR LANDMARK STATE PLAN I.D. NUMBER <br /> -eP P arc ?So7 <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): 7�1 <br /> THIS PERMIT IS FOR A: <br /> 5'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 ❑ 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 Site <br /> Septic Tank Capacity <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity p ZJ <br /> Manufacturer: I AJ ites-ii (meq L <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 /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> Private ❑ Joint ❑ Public <br /> I,the undersigned,hereby assume responsibility for stallation of the private sewage system shown on the attached plans. <br /> Nam of lumber Pri tl: Sign r MP/MPRSW No.: jPhone Number: <br /> Vigil <br /> Plu e 's Address: <br /> Name of Designer. <br /> W � ' <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> Oc _ <br /> eo _/// r/6 ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> ,Reason for Disapproval: 7r <br /> l <br /> Alternate courselsI of Action Available: <br /> DILH R-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />