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D =4 SANITARY PERMIT APPLICATION <br /> U.01 In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> BURNETT <br /> STATE SANITARY MIT#/�I �' <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than /T//S-s63) <br /> 8%x 11 inches in size. ❑ Check if revisio o 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 PROPERTY LOCATION <br /> TRACY DURAND SW % SE +%, S ­14 T 40 , N, R 14 , lV� W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# N/A BLOCK# N/A <br /> 1598 CHRISTNER ROAD <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> SPOONER WI 54801 N/A <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> YpYyI� ❑State Owned VILLAGE: SCOTT CHRISTNER ROAD <br /> ❑ Public 1N 1 or 2 Fam. Dwelling-#of bedrooms- AR X NUMB ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo I / V TvIJ <br /> 2 ❑ Assembly Hall 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. ❑ 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 /> A. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOuIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 410 420 .71 <3 93.3 Feet 95.8 Feet <br /> VII. TANK CAPACITY Site <br /> In Gallons Total of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 8001 1 8001 1 <br /> Lift Pump Tank/SI hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): ature:( Stamps) 4V/MPRSW No.: Business Phone Number: <br /> Plumber's Sign <br /> MELVIN J. FERGUSON 1 635-7482 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> HCR 59 BOX 4' SPOONER, WI 54801 <br /> IX. COUNTWDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent S' nat a(No s <br /> u <br /> Approved El Owner <br /> Fee)Owner Given Initial ql O� � <br /> Adverse Determination —1e di <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 />