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eiii0000i =�^s^ APPLICATION FOR SANITARY PERMIT <br /> � DILHR )_ ?1 e* —COUNTY <br /> (PLB 67) UNIFORM SANI ARY PERMIT# <br /> sesionni <br /> OEPiSTRY.LT OF <br /> IrIOUSTgV,LRBOq 6Mllmnn FELRT10n5 <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 <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> P OPERTV OWNER / MAILING ADDRESS <br /> b Yvl 4 / c tc. E .1 . k-w K� i dd <br /> PROPER T LOCATION CITY: s SS i3 <br /> � C1/�E1/4, S T , N, Rl� ) W O NOF' J� Cf�So,� <br /> LOT NUMBER BLOCK N MBER SUBDIVISION NAME ES OAD LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> 5S Vo rvrN, �3 e l-i oto 4 <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 ❑ 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 <br /> G [ <br /> rr l Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity S 1 ( PL <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: CiTIc I-e iil"Q 4 t <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/$iphon Chamber <br /> Manufacturer: <br /> 1PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feetl: PROPOSED (Square Feet): <br /> -3-3— q I &I !S— 1 ksc 1 7V Private ❑ Joint ❑ Public <br /> 1,the undersigned, hereby assume responsibility for nstallation of the private sewage system shown on the attached plans. <br /> Name o Plumber (Pr tl: Sig use: MP/MPRSW No.: Phone Number: <br /> �S aof r <br /> Plumber's AName of Designer: <br /> -edress: Wts 3 AvP�s �� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si nature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> n C7 <br /> J Owner Given Initial <br /> �J Approved Adverse Determination <br /> eason for Disapproval: F <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD-6398 (R.5/62) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />