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�ILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis. Adm. Code BURNETT <br /> STATFSANITARYP RMIT# <br /> I40'I--! <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.N MBER <br /> 8Y=x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> JOHN MENTH SE y4 SE y, S 10 T 40 N, R 14 El( 4W <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNUMBER BLOCKNUMBER SUBDIVISION NAME <br /> 4915 RUSSELL AVE S. 18 & 19 NA GOV LOT 1 <br /> CITY,STATE ZIP CODEUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> MINNEAPOLIS,MN 55410 PHONE NFgTVOILWLANGOE, SCOTT ROONEY LAKE <br /> It. TYPE OF BUILDING OR USE SERVED: o <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. 1!1 New b. 0 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. El The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. 0 Conventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. D Mound I. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. [N Seepage Bed b. 0 Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): I <br /> 3 *1 U <br /> ' 96. 5 Feet Private ❑Joint El Public <br /> VI. TANK CAPACITY Site <br /> in 11 ns Total #of Prefab. Fiber- Eger. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank �rl ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ I ❑ <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): Plumber's Signature: No Sta ps) MP/MPRSW No.: Business Phone Number: <br /> ARLYN J. HELM 3360 715 )625-7595 <br /> Plumber's Address(Street,City,State,Zip Code: Name of Designer: <br /> P.O.BOX 71, SPOONER, WI 548101`1 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> MARCEL McCUMBER 2710 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> P.O.BOX 66, MINONG, WI 548591 715 466-4793 <br /> JX4 COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved S nitary Permit Fee I Groundwater, ale Issuing en[Signature(No Stamps) <br /> A.Approved ❑ Owner Given Initial �/crn� S charr�ge F,pEe�e��� //y(�) �y <br /> Adverse Determination ` �J A,�U r 3f'�`�r ' <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 />