Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> 751LHR In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> BURNETT <br /> ���• � STATE�AAANITAR RMIT#/S MEb <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ / i�� <br /> 814 x 11 inches in size. k If revlslo 5AO previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER I PROPERTY LOCATION <br /> MARVIS 14eRA-�+ SE ya NE ya, S 34 T 40 N� R 14 �� W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK <br /> HCR59 #27549 SHAKE ROAD 1,.Lo-r N/A <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> SPOONER, WI 54801 NIA <br /> II. TYPE OF BUILDING: (Check one) CIN NEAREST ROAD <br /> State Owned VILUGE SCOTT SHAKE <br /> ❑ Public ❑X 1 or 2 Fam. Dwelling–#of bedrooms R ELTAX NUM <br /> III. BUILDING USE: (If building type is public,check all that apply) (/ / J 3/ ' _ /_—/ <br /> 1 El Apt/Condo O— �I T / <br /> 2 El AssemblyHall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. M Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 720 720 .62 43 93.8'Feet 95.6 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> INFORMATION in Fist Tons tal #of Prefab. fiber- Exper. <br /> New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdina Tank 10,001 1 10001 1 1 SKAW <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the oppite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plum 's ignature: No Ips) 11i/MPRSW No.: Business Phone Number: <br /> MEL FERGUSON 3393 715r635-7482 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> HCR 59 BOX 478d SPOONER, WI 5 O1 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> r'/ a e Disapproved Sanitary Permit Fee(Includes Groundwater ssu Issuing Agent Signature(No Stamps) <br /> Lly Approved 01 Owner Given Initial I _ surcharge Fee) / <br /> / \ A vera D t rminati I cc �-�-�/ CG✓7� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />