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EZ : <br /> APPLICATION FOR SANITARY PERMIT <br /> ILHR Burnett rOUNTY <br /> lEn (PLB 67) UNIFORM SA ITARY PERMIT # <br /> i YLR OFr V,LRBOR6HUrfIRIIRELRiIOnS <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. /1 <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> DougJiracek 11009 Little Aye- S BIrtorningfin,nl IVIN r5)427 <br /> PROPERTY LOCATION XMXX: <br /> XXXXax <br /> GL2 1/4 1/4, S 2 , T40, N, R 1 W TOWN OF: <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> na na na Pratt Rd. Green Lake 850268 <br /> TYPE OF BUILDING OR USE SERVED <br /> RJ 1 or 2 Family Number of Bedrooms. 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> U 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 /> ❑ Seepaye Bed ❑ Seepage Trench ❑ Seepage Pit 5d 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 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity 2000 1 <br /> Manufacturer: <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site $reel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> na na na ❑x Private ❑ Joint ❑ Public <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print): Signatu MP/MPRSW No.: Phone Number: <br /> Donald Daniels MP 330 T15 463 2333 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren, WI 54872 1 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> n !/f p °O ❑ Owner Given Initial <br /> ZAPProved Adverse Determination <br /> eason for Disapproval: Fl <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD-6398 1R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />