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D�LHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> _�'"'"'-------- BURNETT <br /> STATE SANIT YPERMIT#OoCtVV 7nt7O`f <br /> �1, <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> ❑ i� a� <br /> 8%x 11 Inches In size. re ion to 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 PROPERTY LOCATION <br /> KEN MILLER -- '/4 -- 144,S 36 T40 , N, R14 /Ff(,6 <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# LOT 2 BLOCK# <br /> 27476 HILL ROAD PT OF GOVT LOT 2 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> SPOONER WI 54801 63 -7710 VOL 6 CSM PG 99-100 <br /> El <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned CILLAGE ITY NEAREST ROAD <br /> �y�I HILL ROAD <br /> ❑ Public TJ 1 or 2 Fam. Dwelling-#of bedrooms 3 PARCEL TAX NUM <br /> III. BUILDING USE: (If building type is public,check all that apply) ag— Ll136� Dp�-LjC� <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 100Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel g ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. 2 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 /> 11XD8respageBed (LIFT) 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 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 720 J 720 .625 3 95. 7 Feet 98 . 2 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New Istin Gallons Tanks ncret glass App. <br /> Tanks Tanks strutted <br /> Septic Tank orNoldi ank- 1001 110QQI1 SKAW <br /> Lin Pum C <br /> Tan onhambar 600 600 1 COMBINATION <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): lumber's Sign re:(No Stamps) -WMPRSW No.: Business Phone Number: <br /> MEL FERGUSON 3393 715 35 7482 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> HCR 59 BOX 478d SPOONER, WI 4801 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing a Sig ure(N S mps) <br /> Surcharge Feel <br /> Approved ❑ Owner Given Initial —'7/ <br /> A Determinationv't <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-3393(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />