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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> 17- In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> .e..r�•�,�.,e� STATE�ANITARY RE RMIT#1954/'c) <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ / /(�95a 1 Y7 b <br /> 8'%x 11 inches in size. c k If revisi to previous application <br /> —See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT <br /> EINFORMATION-PLEASE PRINT ALL INFORMATION. 593-02 <br /> PROPTaTnY W NFRltz GL 1 PROPERTY LOCATION <br /> ffLL aY /a /a,S 12 T37 , N, R 18 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# //11 BLOCK# <br /> 4703 6th St NE QV 't. Lur na <br /> CIN,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Columbia HeiAotj 55421 612 572-0134 na <br /> IL TYPE OF BUILDING: (Check one) CITE NEAREST ROAD <br /> ❑ State Owned TnWN E:TnF. rade Lake Spirit Lake Access Rd <br /> ❑ Public Ell or 2 Fam.Dwelling-#of bedrooms EL Nu R( <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 034-1512-03-100 <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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. 0 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 �IX 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 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> 300 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- p . <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass A <br /> Plastic App. <br /> strutted <br /> Tanks ITanks <br /> Septic Tank or Holding Tank 1111 Ah -- <br /> Lift Pump Tank/Siphon Chamber 66.7 <br /> Vlll. 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): Plu"SIgnatur N mps) • MPIMPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 715 349-5533 <br /> Plumber's Address(Street,City,State,Zip Comy <br /> PO Box 316 Siren WI 54872 <br /> IX. OUNTYrTMENT USE ONLY <br /> pproved Sanitary Permit Fee(includesGroundwater ae ssu IssumgA ntSi netur (N Stamps) <br /> Surcharge FeeApproved er Given Initial '��Ie Determin tion �../ <br /> OD <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />