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MMMI <br /> SANITARY PERMIT APPLICATION C UNITY <br /> "�-DMHR In accord with ILHR 83.05,Wis.Adm. Code Burnett <br /> Sl ATE SANITARY ERMIT#,, 1 <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than SATE PLAN I.D.NUMBER <br /> 8'F:x 11 inches in size. ���00� <br /> -See reverse side for instructions for completing this application. <br /> P TITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F R VARIANCE []YES IXNO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Penny King Gull Lake Resort GL 1'/, %, S 2 T40 , N, R 16 xEt(nx) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> Rt. 1 Box 430 nana n <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> Danbury, WI 54830 D VILLAGE: Oakland Gull Lake <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ❑ 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. ❑ The 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. x]Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.1-1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. XSeepage Bed b. ❑SeeDacie Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 3 410 420 92.50 Feet ❑P ivate ®Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ 1 ❑ ❑ ❑ ❑ <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): Plumber�(No Sta� MP/MPRSW No.: r"15 <br /> iness Phone Number: <br /> Donald Daniels MPW 330 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Box W, Siren, WI 54872 Same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan DAniels 34,1 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Numb r: <br /> Box W, Siren, WI 54872 715 349-5533 <br /> I . COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuin gent Si nature(No Stamps) <br /> Approved ❑ Owner Given Initial Q( Co S rrcchargee Fee <br /> (l (/�) <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 />