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ni^ APPLICATION FOR SANITARY PERMIT <br /> =coD I L H R11'LD p 67' Burnett COUNTY <br /> OEPRQTr'EnT OF UNIFORM SANIT RY PERM T # <br /> InOUSTRV.LRBOR 6 HumRn RELRTIOnS <br /> 3S �f% / � <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8%x11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Denis Simonsen Rt. 1 Siren, WI 54872 <br /> PROPERTY LOCATION 1;4dx: <br /> NE NW 2 8 1 XXX= 12: Daniels <br /> 1/4 1/4, S 3 , T 3 , N, R 7 *45r) W TOWN OF: <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> na na na Waldora Road na <br /> TYPE OF BUILDING OR USE SERVED <br /> Ei 1 or 2 Family Number of Bedrooms: TEJ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> E-3 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 /> Lj Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ 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 1000 1 X <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: TMC Inc. Poskin, WI <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site Steel 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 /> 3 615 630 <br /> Q 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): Signature MP/yRR%kjo.: Phone Number: <br /> Donald Daniels 330 1 (715 )463 2333 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren, WI 54872 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign�Issuisn ant- , Fee: Date: ❑ Disapproved <br /> _1 El Owner Given Initial <br /> gPp,ovad Adverse Determination <br /> ason for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />