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T5t 1^ OF <br /> APPLICATION FOR SANITARY PERMIT <br /> Burnett COUNTYDILHR (PLB 67) UNIFORM SANITARY PERMIT# <br /> IlOLSTRY,LRBO6 FVTRI RELRTIOnS� <br /> Q <br /> 7y7tfl ( /,� y.ls) <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Joe Weller 850 Webster Lane Des Planes <br /> PROPERTY LOCATION CITY: <br /> YULLAL E: <br /> -0 Scott <br /> /4 1/4, S T N, R E (or) W wN o <br /> LOT NUMBER BLOCK NUMBER SUBDIV ISIO NAME— NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> NA NA GeV. lot # Rooney Li4ke <br /> TYPE OF BUILDING OR USE SERVED <br /> ,)1 1 or 2 Family Number of Bedrooms: 2 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 0 New System ❑ Tank Replacement ❑ Repair <br /> X Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> EC] Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy <br /> ❑ Existing, For Which A Previous Permit Is On File, Permit # issued <br /> ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: wieQers <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA yt1ATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feetl: PROPOSED (Square Feet): <br /> 3 410 /l7 _3 of ® Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na of Plumber (Pr' t): Signa �/ MP PRSW No.: Phone Number: <br /> 2 ll �- Co Z SO nor I z �7Z <br /> P umb. dress: -}�-- N of esigner: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ure of Issuing Agent: Fee: Date: ❑ Disapproved <br /> / �(r' [� q ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> eason for Disapproval F <br /> Alternate courses)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />