Laserfiche WebLink
E <br /> °�^�^ APPLICATION FOR SANITARY PERMIT E <br /> D I L H RUYA4 <br /> BOUNTY <br /> � p0UST1 nenToc (P LB 67) UNIFORM/SANITARY PERMIT # <br /> - If10115TgYBrI IOr1 <br /> ,lFOR6MVTRRELRT5 796 / Y //L�Y/r/\ <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. ` (o J <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PRO ERTV OWNE MAILING ADD SS <br /> G��4/ tir t� ter- �f - ti ; E,/ <br /> PROPERTY LOCATION CITY: <br /> vILL GE: <' <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAMEESOTv OA LAKE OR_AI DMARK STATE PLAN(N I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED QQ// OT <br /> X1 or 2 Family Number of Bedrooms: 3 FjPublic (Specify: <br /> THIS PERMIT IS FOR A: <br /> ❑ New System Tank Replacement ❑ Repair <br /> yX 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. Qe t4,/9 <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 /> Private Ll Joint ❑ Public <br /> 1, the undersigned, hereby assume responsibility for insIlation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print SignatIt MP/MPRSW No.: Phone Number <br /> ur : <br /> S o `HPVtY (7r,) �6 <br /> Plumber's Address: Name of Designer: <br /> eS'FS`t 3 tve1,r Boer r <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig ur of Issuing t: Fee: Date: ❑ Disapproved <br /> 00 r/ ❑ Owner Given Initial <br /> :5--36)-,F4 <br /> `—3O—Q 6 Approved Adverse Determination <br /> peibson for Disapproval: <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 />