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f� w,=°�^_�^ APPLICATION FOR SANITARY PERMIT _ _ <br /> D I L H IF �'ri-t'NIT COUNTY <br /> (PLB 67) <br /> >_ oeRrwT Y.LRB UNIFORM SANITARY PERMIT # <br /> r10 V ST R V,LRBOR 6 MUTRrI RELRTIOr15 <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 81/zx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERJY OWNERMAILING ADDRESS d LV /� % <br /> 60. le d 6 <br /> PROPERTY LOCATION I CITY: <br /> S'E1/45&/4, S T3 fN, R /7ff (or) W TOWNOF: nlGJ IA/ <br /> LOT NUMBER BLOCK NUMBER SUB DIVI��N AME ROAD, LA OR LANDMARK STAR PLA� D. NUIy1BER <br /> TYPE OF BUILDING OR USE SERVED R S "/7/Nr <br /> 1 or 2 Family Number of Bedrooms; .01, TP,blic (Specify): <br /> THIS PERMIT IS FOR A: <br /> XNew System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> El 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: <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 ,y O <br /> Lift Pump/Siphon Chamber 7 lv y <br /> op <br /> Manufacturer: W C <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA <br /> (Minutes per inch): REQUIRED (Square Feet l: PROPOSED (Square Feet): rWATER SUPPLY: <br /> . a S v a 7 a- Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> e of pglumber (Prin`tl: ,(� Sig tures MP/MPRSW No.: Phone Number <br /> NO Wa : <br /> o A 1c, ATO OS /S) 0�� <br /> Plumber'sdres Name of Designer: <br /> w sY� f 3 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign re of Issuing Agent: Fee: Date: El Disapproved <br /> ° /�I <br /> �/ _ (�/ <br /> �/_ 7�; c G' ElOwner Given Initial <br /> �at7G-C'f C C��u.�,r Approved Adverse Determination <br /> son for Disapproval: <br /> � t <br /> i <br /> Alternate course(s)of Action Available: <br /> DI LHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />