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SANITARY PERMIT APPLICATION Go NTY <br /> � DILHR Burnett <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> t= s STI TE SAN�I/TARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STi TELAN I.D. MBER <br /> 8'%x 11 inches in size. 6 6 Z 0040 <br /> -See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FO I VARIANCE ❑YES ® NO <br /> PROPERTY OWNER L% %, <br /> ON <br /> David N. Volkmann S 34 T38 N R 1 xEW W <br /> PROPERTY OWNER'S MAILING ADDRESS LOCK NUMBER SUBDIVISI N NAME <br /> 3009 Harding St. N.E. na na <br /> CITY,STATE ZIPCODE PHONE NUMBER NEAREST AD,LAKE OR LANDMARK <br /> Mpls. , MN 55412 612 786-7341od River Wood aloe <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ❑x 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 Agreeme nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ❑Conventional b. x❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. R] 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 14. ABSORPTION AREA 15.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Feet ❑P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> I <br /> n allons Total #of PrefabFiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name .Concrete Con- Ste I glass Plastic App <br /> Tanks I Tanks structed <br /> Septic Tank or Holding Tank 3000 -- 30001 TMC Inc. ® L-1Lift Pum Tank/Siphon Chamber, ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans - <br /> Plumber's Name(Print): Plu is Signature:IN Stamps) MP/MPRSW No.: Bu mesa Phone Number: <br /> Donald Daniels MP 330 15 349-5533 <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 3431 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Numb r: <br /> Box W Siren, WI 54872 715 349-5533 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee I Groundwater rffa7e____7 Issuing Agent Sil nature(No Stamps) <br /> Approved ❑ Owner Given Initial `�}. Surcharge Fee JQ_�ID t� <br /> Adverse Determination � "' 6/ l <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />