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APPLICATION FOR SANITARY PERMIT <br /> . Aaz�� COUNTY <br /> DILHR <br /> (PLB 67)1111111 DEPRRTTT1ErlT OF UNIFORM SANITARY PERMIT# <br /> - 1nOU5TRV,LRROR&HUmRn RELRTlOnS �/_97 <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 sized. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PR° �RTY OWNER-, MAILING XDRESS <br /> / r 0`1 inn n i\ L%j I <br /> PROPERTY LOCATION CITY: <br /> 1/4 SZ-1/4, S off- , T '/0N, R / * (or) W FNART <br /> = <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> AIAJUG- �. C47 0go 'r <br /> TYPE OF BUILDING OR USE SERVED <br /> ❑ 1 or 2 Family Number of Bedrooms: Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System 5e Tank Replacement ❑ Repair <br /> X 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 Constructed <br /> Septic Tank Capacity <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: uj C <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 installation of the private sewage system shown on the attached plans. <br /> Na f Plumber (Print): Si u MP/MPRSW No.: Phone Number: <br /> d Yo°/c r1 iv1 S {�Z � 00L& <br /> �!7 <br /> P umber's Address: A Nr e of Design <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: <br /> ❑ Disapproved <br /> D <br /> Z&4�� 7_3f.�i5/ El Owner Given Initial <br /> 7 Approved Adverse Determination <br /> ason for Disapproval: IQ <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 />