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SANITARY PERMIT APPLICATION COUNTY <br /> D14HR In accord with ILHR 83.05,Wis. Adm.Code BURNETT <br /> �• STATE SANIT YP RMIT# <br /> INA <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.fWMBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE ITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F VARIANCE EIYES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> MIDWEST CRANBERRIES (C. KRONLUND) SE '/4NE '/4, S 1 T 39, N, R 14 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> STAR RT BOX 473 NA NA NA <br /> CITY,STATE ZIP CODE PHONE NUMBERCITY 'PIUSr. NEARES OAD,LAKE OR LANDMARK <br /> SPOONER WI 54875 VTOWN OF <br /> ILLAGE : <br /> II. TYPE OF BUILDING OR USE SERVED: I <br /> Number of Bedrooms if 1 or 2 Family 3 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. ElThe System is shared by more than one owner/building. Attach Common Ownership Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. Q Conventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.Ll Pit Privy d. ❑ Vault Privy e. ❑ Mound I. �❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ® See a e Bed b. ❑ See a e Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> <3 615 Feet OPrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank orHoldin Tank 000 000 1 WIESER' S ❑ D I ❑ <br /> Lift Pump 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:(Nos mps) MP/MPRSW No.: B smess Phone Number: <br /> ARLYN J. HELM _ r r <br /> Plumber's Address(Street,City,State,Zip Code : Name of Designer: <br /> P O BO <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> MELVIN J FERGUSON <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing gentSgnature(No Stamps) <br /> Approved ❑ Owner Given Initial �/h /r71 rc�a eP�exe, /i-� 00 � <br /> \ Adverse Determination CD O J U ) 1.) o a <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 />