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ILHR SANITARY PERMIT APPLICATION COUNTY <br /> TffIn accord with ILHR 83.05,Wis. Adm.Code BU'ZNcTT <br /> ST TESANITARYP RMIT# <br /> 4 <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than ST TE PLAN I.D.NUMBER <br /> Wh x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 3TE <br /> KATHY P ;SON SE '/4 SE '/4, S z 3 T 38, N, R 1 X�r W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> i�OUTE ;� 1 NA 14A NA <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD LAKE OR LANDMARK <br /> 3T-L':LL LAKs, 54.871 469468-77 VILLAGE : DE(xji;Y S TIS MALET '.0 <br /> TOWN OF <br /> If. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms it 1 or 2 Family OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. ❑ New b. `iJ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.lp Repair of an <br /> System System Septic Tank Only an Existing System Existing System <br /> 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. <br /> 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) I'I <br /> 1. a. r Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ❑ See a e Bed b. ❑Seepage Trench C. ❑ See a e Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): 93- 0 <br /> 945 94.5 71/0 Feet ®P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> In allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New oonse g Gallons Of Manufacturer's Name Concrete Con- SteEI glass Plastic App <br /> Tanks Tanks I� structed <br /> Septic Tank or Holdin Tank 100 1000 1 kJI_SS'—'. �rS L� ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 1 1 1 1 ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Bu, iness Phone Number: <br /> ARLYTI J. H?Lb, 360 715 635 7595 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> P.O.BOX 71, uP00TvER, WI 54.801 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> S AT':'IF <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Numb r: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved [s5a_tary Permit Fee Groundwater ate Iss Agent Si re(No Stamps) <br /> Approved ❑ Owner Given Initial �/1 AS1 ��e/F�e-e� 'V <br /> Adverse Determination d,,J L_J <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumberl� <br />