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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> BURNETT <br /> mmmw� mw STATE SANITAR ERMIT#/�� � <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ��S�i <br /> 8'f x 11 inches in size. ❑ Check If reviskinto 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 LERACATION <br /> JAMES STEEL 'Ya, S26 T 39, N, R 14'�/9' WPROPEE320y/NEr1R'S MAILING ADDRESS N/A BLOCK# N/A <br /> CITY,STATE!!}} ZIPCODE PHONE NUMBER NAME OR CSM NUMBER <br /> HUDSON WI 54016 II. TYPE OF BUILDING: (Check one) NEAREST ROAD <br /> State Owned :RUSKYELLOW RIVER <br /> ❑ Public ®1 Or 2 Fam. Dwelling—#of bedrooms� NUMBER( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) <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 ❑ RestauranUBar/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 /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2,ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 410 420 .71 3 94.7 Feet 96.2 Feet <br /> CAPACITY <br /> VII. TANK in allontt Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdino Tank001 800 <br /> Litt Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation oft YTnsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): umber's Signatre: Stamps) Tarr/MPRSW No.: Business Phone Number: <br /> MEL FERGUSON 3393 715 35-7482 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> HCR59 BOX478d SPOONER, WI 801 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater aessue Issuing Agent i atur (No s) <br /> surcharge Fee) <br /> Approved ❑ Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />