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MMM T Mill <br /> DtLt-tR SANITARY PERMIT APPLICATION COUNTY BURNETT <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> �• _� STATESANTARYP MIT#J;N333� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than f C{l/Ll <br /> 8'/i x 11 inches in size. ❑ check it revision 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. S89-20354 <br /> PROPERTY OWNER _ PROPERTY LOCATION <br /> CAMP CRIOX-RICHARD BIERBAUER NW %SE '/4, S 10 T40 , N, R 14 ) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> ROUTE #1 BOX 149 NA NA <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> OSCEOLA, WI 54020 <br /> ID CITY NEAREST ROAD <br /> It. TYPE OF BUILDIIN�NIG: (Check one) ❑ State Owned VILLAGE SCOTT RONEY <br /> Public I-11 or 2 Fam. Dwelling-#of bedrooms PA ELTA NUMB ( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) cz�- qliI Q - v 1 -C:;�Co <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ® Outdoor 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 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. 0 New 2. o 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 /> 11 '❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 Q Holding Tank <br /> 12 fl Seepage Trench 22 gin-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 13.ABSORP.AREA 4. LOADING RATE 5. PER' RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 2025 2562 2562 5.9 <3 91. 3 Feet 92 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> structed <br /> Tanks Tanks <br /> Se tic Tank or Holdin Tank 2500 <br /> Lift Pump Tank/Siphon Chamber Juuy 13000 1 1 1 WIESER' S <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): Plum er's Signature:(Nos s) MP/MPRSW No.: Business Phone Number: <br /> MELVIN J. FERGUSON .ZZLA.K. 715 635-75 5 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> P.O.BOX 71f SPOONER WI 54801 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate Issued Issuing Agent Signature(No Stamps) <br /> �l <br /> Aproved pEl Owner Given Initial y,t IhlS Surcharge reel <br /> Adv Determination Jy W / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb$7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 6 Buildings Division,Owner,Plumber <br />