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F:Ymt��n SANITARY PERMIT APPLICATION <br /> In accord with IL}1R 83.05,Wis.Adm.Code couNTv <br /> BURNETT <br /> STATE NITARY PERMIT#IOh <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than /OU <br /> 8%x 11 inches in size. ❑ LW,revl2 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 /> GENE KORDUPLESKI =- '/4 = '/4, S 3.15 T 39 , N, R 14//E/(6 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1964 DEER TRAIL RD A1111111? I N/A <br /> CITY,STATEZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER �7 <br /> SPOONER, WI 54801 J' + 3 P k �;tO ) TV's• LG <br /> 0 CITY <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned 1:1VILLAGE NEAREST ROAD <br /> IR OF <br /> DEER TRAIL <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 3 A L AX u ( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) <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. X❑ 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. Permitii — 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 ❑ 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 PEW7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(s .ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 720 7 .8 3 93 .4 ' Feet 96 .4 'Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tenks Manufacturer's Name oncret onSteel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 10010O <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility f r installation o the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): lu er's Si natu :(No Stamps) IjWMPRSW No.: Business Phone Number: <br /> MEL J. FERGUSON ,4 3393 715 35 7482 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> HCR 59 BOX 478d SPOONER, WI 54801 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwatera eIssuedIssuing A Sign ra tamps) <br /> Approved ❑ Owner Given InitialSurcharge Fee) / <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />