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� D I L H R APPLICATION FOR SANITARY PERMIT <br /> Burnett COUNTY <br /> (PLB 67) UNIFORM SA TARY PERMIT # <br /> OEPiin <br /> ..TRY <br /> OF \ <br /> neoe 6MurMniiElaTlOns / q � � <br /> /17 <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8'/sx1�F1'iin/ches in size. f <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Wm. J. Rank 1704 East 58th St. Minneapolis, MN 55417 <br /> PROPERTY LOCATION <br /> GL51/4 1/4, S 13 , T 40, N, R 15 E)&*r) W TOWN OF: Jackson <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> 5 na na Birch Island Lake na <br /> TYPE OF BUILDING OR USE SERVED <br /> y� 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 5d 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 /> Ed 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 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: TMC Inc. POski.n WI <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. 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 y1/gTER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> 2 619 630 ® 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: ,r MP/MPRSW No.: Phone Number: <br /> bonald Daniels [J MP 0 1 (71 5 )463 2 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren WI 54872 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign a of Issuin ent: J Date: / ❑ Disapproved <br /> ❑ Owner Given Initial <br /> . J Approved Adverse Determination <br /> son for Disapproval: <br /> Alternate courses)of Action Available: <br /> DI LHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />