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W5c�e.,^ N APPLICATION FOR SANITARY PERMIT <br /> �r D I L H RBurnett COUNTY <br /> oERRRTmenr ae (PLB 67) UNIFORM SANITA PERMIT # <br /> InOUSTRV LRBOR 6 Humen RELRTions /� <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8%:x11' in(/ches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Monroe T. Blomgren Rt.1 Box 180 Grantsburg, WI 54840 <br /> PROPERTY LOCATION <br /> 1tGEaEXLtX <br /> SW 1/4 NW1/4 S 19 , T 38 N, R 17 )9f4r) W TOWN OF: Daniels <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> na na na County "W" 86-03626 <br /> TYPE OF BUILDING OR USE SERVED <br /> Dt 1 or 2 Family Number of Bedrooms: 2 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> FYJ New System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> ❑ 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 2000 1 x <br /> Manufacturer: TMC Inc. Poskin WI <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> na na na ❑X Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Ptumber (Print): Signa MP/MPRSW o.: Phone Number: <br /> Donald Daniels ?y* MP 330 T15-463-2333 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren, WI 54872 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signet f Issuing A e e: Date: ❑ Disapproved <br /> /� �]_.� ❑ Owner Given Initial <br /> C,T / pproved Adverse Determination <br /> son for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DfLHR SBD-6398 IF, 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />