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[7-71APPLICATION FOR SANITARY PERMIT <br /> OUNTY <br /> DILHR <br /> (PLB 67) UNIFORM SANITARY PER IT # <br /> InDUS RV,r1T Or <br /> �Il101ISTgV.LgBOg6MUmgr1RELRT10115 <br /> 7V is oa <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8Y x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> POPERTY OWNER Q M LING ADpRESS <br /> Orr Ol V 3 S- o r� � ! bG �, <br /> PROPERTY OCATION I CITY: <br /> V <br /> IV 1/4Lt11/4, S T (� N, R s (or) W owN oI, aI C f S A <br /> LOT NUMBER BLOCK NUMBERDDIIIVISION flJAQME / �— AREST RO�iD LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED /�!O <br /> X 1 or 2 Family Number of Bedrooms: .3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ 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 # 4 #133/d 5,)0.4 M9Af3 issued 3—/y 75/ <br /> ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. <br /> Total #of Prefab. Site <br /> —/� Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity „-{'� ,$/� y hi <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 - <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREAABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED 7` (�Square Feet): <br /> I_ip ��� 6 0{ 0 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N e of Plumber (Print): SiC�°'7;�e: MP/MPRSW No.: Phone Nu be r! <br /> C r- r-is C �t S /C" � J �/J )1�/a6' <br /> Plumber's Atresr Name of Desig er. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa re of Issuing Agent: Fee: 6 7;e ❑ Disapproved <br /> j ❑ Owner Given Initial <br /> yApproved Adverse Determination <br /> Offason for Disapprov I: <br /> Alternate course(s)of Action Available: <br /> DI LHR SBD6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />