Laserfiche WebLink
�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> Burnett <br /> �• <br /> momm� STATE SANITARY PERMIT#)'a�S(� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ec��y)Wy� <br /> 8%x 11 inches in size. chk If revisi n to 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. o_ <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Clare Lidel GL 1 NW t/4 SW 1/4, S 26 T 38 , N, R 15 R for W " <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Rt. 3 na I na <br /> CITY,STATE 21P CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Frederic WI 921837 15 ) 653-2562 na <br /> El <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned ❑ CITY NEAREST ROAD <br /> VILLAGE LaFollette Spencer Lake Rd, <br /> ® Public ❑1 or 2 Fam. Dwelling-#of bedrooms— PAR L XNUCI ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 014-2226-03 100 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/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. ❑x 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 PER77 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE '_ PE <br /> . PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED AREA <br /> ff.) PROPOSED(sq.ft.) (Gals/day/sq.f (Min./inch) ELEVATION <br /> 4000 4000 4000 1 3 98.35 Feet 101 .35 Feet <br /> VII. TANK CAPACITY Site <br /> In allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New iss Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank -)0001 <br /> Litt Pump Tank/Siphon Chamber 6000 <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): Plu er'a Signature:(No tamps)- MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 715 349-5533 <br /> Plumber's Address(Street,City,State,zip Code): <br /> PO Box 316 Siren, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIs i Agent S!gnat (No Stamps) <br /> Approved <br /> El Given Initial C surcharge reel �( <br /> Adverse n /1.'S<X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />