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uamconsin APPLICATION FOR SANITARY PERMIT <br /> � D 1 L= H R (PLB 67) Burnett COUNTY <br /> UNIFORM SANITARY PERMIT# <br /> � OEPRGTTEfIT OF <br /> - IrIOUSTRY,LRBOR6MUmfJI"1RELnTIOfIS <br /> 276 ( IN36i)I <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm, Code for the system,on paper not less than 81hx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Helmer Aronson Rt. 2 Webster WI 5489 <br /> PROPERTY LOCATION 4T� <br /> S21 4/4 SW 1/4, S 33 , T 39, N, R 17 E1 WYW TOWN OF: Lincoln <br /> LOT NUMBER I BLOCK NUMBER I SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> NA I NA County Road D NA <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): NA <br /> THIS PERMIT IS FOR A: <br /> ❑ 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 /> ® 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 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: TMC TNr <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> #ofTotal Tanks <br /> Pretret 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 /> 4 615' 630' n 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: 99 MP/ P No.: Phone Number: <br /> Donald Daniels 330 (715 )463-2333 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren, WI 54872 Same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa re of Issuing Agent: Fee: Date: <br /> ElDisapproved <br /> %Q�% / a/_�y ❑ Owner Given Initial <br /> �'j.Ll1 '�L� l� (1! tp Approved 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 />