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OEPRRTTE,nT OF APPLICATION FOR SAN <br /> IARY PERMIT / y �/ <br /> /COUNTY <br /> (�� DILHR (PLB 671 UNIFORM SANITARY PERMI <br /> In0USTRVLRBDR&.u.1 LR`non5 <br /> # <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 87:x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER// D MAILING ADDRESS <br /> DI C /r 4 9 P.4 st s �C / f H v &17011,e � <br /> PROPERTY LOCATION <br /> IV W1/4$W%/4, S �O , TyQN, R / Er(or) W TOWN : U Q4-4 e t III <br /> LOT NUMBER BLOCK NU BER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> Iv C c /Q <br /> TYPE OF BUILDING OR USE SERVED <br /> Lyf 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> EX 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 /> 7 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 <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATEABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): 7 PROPOSED (Square Feet): <br /> 3 o/ _� iA_ I IX Private ❑ Joint ❑ Public <br /> 1,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N e of umber (Print): Si tur MP/MPRSW No.: Phone Number: <br /> 0 e r�'C fT A 0'gC 3 C Y (?/r) f66-v1s'7 <br /> Plumber's Aftes- Naof De 'goer: <br /> � CCC777 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa re of Issuin Agent: Fee: D Date: <br /> ❑ Disapproved <br /> �/� ❑ Owner Given Initial <br /> d / O �4.APproved Adverse Determination <br /> son 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 />