Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY Burnett; <br /> :ED%.H R In accofd with ILHR 83.05,Wis. Adm. Code mmumme STATE SANITARY PERMIT# <br /> /.-��� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. 86-07241 <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FC R VARIANCE ❑YES ® NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Dick Frees L 1 '/4 '/4, S 26 T38 , N, R18 >fcom) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBERLJ CITY <br /> SUBDIVISION NAME <br /> Grantsburg, WI na na <br /> CITY,STATE Zle COD PHl]JyEJJUMdE,B-54II3 O VILLAGE: ROAD,LAKE OR LANDMARK <br /> 74254 /17 `�c.S d Lake <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 3 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 AgreemE nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ❑Conventional b. [�Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ® Mound f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ❑ Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPO37DD(Square Feet): <br /> 3 6 mound Feet 0 Pi ivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK #of Prefab. Site Fiber- Exper. <br /> in aI s Total Manufacturer's Name Con- Ste I Plastic <br /> INFORMATION New <br /> Its <br /> Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1000 -- 1000 1 TMC Inc. <br /> LiftPum Tank/Siphon Chamber 1000 1000 1 TMC Inc. ❑ ❑ ❑ <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): Pi u is Signature:(No tamps) MP/MPRSW No.: Bu iness Phone Number: <br /> Donald Daniels MP 330 715 463-2333 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Box W Siren, WI 58472 same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name E!it <br /> Joan E. Daniels CST's ADDRESS(Street,City,State,Zip Code) r:Box W Siren, WI 54872 63-2333 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> \ly/I ❑ Disapproved Sanitary Permit Fee Groundwater ate Is ing Agent Signature(No Stamps) <br /> I/7,�pproved ❑ Owner Given Initial � Cc Surcharge Fee ��/� n <br /> / \ Adverse Determination or —CjO j' <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 />