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=mom <br /> DIL,H " SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code Burnett <br /> S1 ATE SANITARY PFR MIT# <br /> Ems <br /> b 0133 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than S1 ATE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE TITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ® NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> Dan Searles GL4 +% /4, S 15 T38 , N, R15 xfx0w)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> Hertel, WI 54845 na na na <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST OAD,LAKE OR LANDMARK <br /> 715 349-5491 EJVILLAGE . LaFolltte Pokega a <br /> fiD TOWN OF: <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 4 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. ® Replacement c. ❑ Replacement of d. ❑ Reconnection of e ❑ 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 Agreem int to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ®Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ® Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 5 820 840 99.00 Feet ®F rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in ga ons Total #of Manufacturer's Name Prefab. Con- Ste Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Se tic Tank or HoldingTank r <br /> Lift Pum Tank/Siphon Chamber L I ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plane. <br /> Plumber's Name(Print): I Plumber's Signature,4No Stamp MP/MPRSW No.: B amass Phone Number: <br /> Donald Daniels '+ ^�`�/� u MP 330 715 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Box W Siren, WI 54872 same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan E. Daniels 431 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Num er: <br /> Box W Siren, WI 54872 715 349-5533 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate Ise Agents a(No Stamps) <br /> Approved ❑ Owner Given Initial S rcharge Fee <br /> Adverse Determination <br /> as.00 Ip-la 8� <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Pb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumbe <br />