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SANITARY PERMIT APPLICATION <br /> 7 0ILHR In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> Burnett <br /> • �_ STATES ITARY PEfIMIT#/�S�n7 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 2b <br /> 8%x 11 inches in size. ❑ Check if revisionA6 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. S89-20356 <br /> PROPERTYOWNER Lna <br /> TION <br /> Guilio Casci t%, S 26 T B , N, R1 g W <br /> PROPERTY OWNER'S MAILING ADDRESS BLOCK# <br /> 2210 Bush St. na <br /> CIN,STATE ZIP CODE PHONE NUMBER ME OR CSM NUMBER <br /> St. Paul , MN 55119 --II. TYPE OF BUILDING: (Check one) NEAREST ROAD <br /> $tate Owned d Liver Count I'M" <br /> Public ©1 or 2 Fam. Dwelling-#of bedroomsMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 042-2526-04-500 <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. x❑ 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 E2 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 PER7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank <br /> Litt Pump Tank/Siphon Chamber <br /> VIII. 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): Plum is Signature:(No mps) MPIMPRSW No.: Business Phone Number: <br /> Donald Daniels �e� MP 330 715 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> PO Box �16 Sirpn WT r4872 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e issuedIssuing Agent Signature(No Stamps) <br /> / Surcharge Fee) <br /> Approved ❑ Owner Given Initial1-4 r��` �� I'1_�1 >�CY . •1 L�.y� <br /> Adv /L Determination n Vl/ /�l� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11188) DISTRIBUTION: Original to County,One Copy To:Safety8 Buildings Division,Owner,Plumber <br />