Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY <br /> pILHR In accord with ILHR 83.05,Wis.Adm. Code BURNETT <br /> STATESANITAR PE MIT# <br /> I��Iq <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 81/2 x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> RICK HARDER SW y,NE +%, S 3 T 39, N, R 14 V (Irr�W <br /> PROP€RTY OWNER'S MAILING ADDRESS LOTNUMBER BLOCK NUMBER SUBDIVISION NAME <br /> STAR ROUTE NA NA NA <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> SPOONER, WI 54801 TILLAGE : RUSK SO. BENOIT LK R <br /> If. TYPE OF BUILDING OR USE SERVED: <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. E� New b. LJ Replacement c. 0.Replacement of d. ❑ Reconnection of e.0 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. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. QConventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. I Seepage Bed b. ❑Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> <3 6. 615 92. 4 Feet ®Private El joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank ❑ ❑ ❑ <br /> Lift Pum 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): Plum er's Signature: No S ps MP/MPRSW No.: Business Phone Number: <br /> ARLYN J. HELM 3360 715) 635-7595 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> P.O.BOX 71, SPOONER, WI 54801 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> MELVIN J. FERGUSON 3669 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> P.O.BOX 71, SPOONER, WI 54801 715 635-7595 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing gent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial •� S ra�e� <br /> Adverse Determination <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 />