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APPLICATION FOR SANITARY PERMIT R <br /> E 77D 1 L H R (PLB 67) COUNTY <br /> oeRRRTmenT ae RM SANITARY PER IT # <br /> InWSTRYLRBOR&HUMINiiTRELRTIOnS UNIFORM <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. <br /> -See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAIL G ADDRESS <br /> K �� r�� � - rxr �y <br /> PROPERTY LOCATION <br /> SkP114 BIN 1/4, S , N, R E (or) TOWN OF: U U 1 t <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NE EST ROAD,�L KE uO,R� LANDMARK STATE PLAN I.D. NUMBER <br /> / - _ V� ZC <br /> TY,,PP�E� OF BUILDING OR USE SERVED <br /> k/// or 2 Family Number of Bedrooms. 3 ❑ Public (Specify): <br /> THIS "MIT IS FOR A: <br /> ff New System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System Ll Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> El Seepage Bed ]L- epage 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 (56 1 �- <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 #ofPrefabte. Site Steel Fiberglass Plastic <br /> Gallons Tanks ConcreConstructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inchl: REQUIRED (Square Feet): PROPOSED (Square Feet 1: <br /> Private El Joint ❑ Public <br /> 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nof PU, U s lumber (Print): // Sign /'� MP/MPR <br /> BW No.: Phone Nu m55ber:p <br /> 5 YL -C c d-SCR a o o ;L <br /> s Address: Na of Dc i ner: <br /> Plumb ' <br /> l i <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa of Issuing ent: Fee: Date: qq ❑ Disapproved <br /> -Ir o / ❑ Owner Given Initial <br /> V Gl ddCC {J APprovad Adverse Determination <br /> eason 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 />