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SANITARY PERMIT APPLICATION COUNTY <br /> �ILHR In accord with ILHR 83.05,Wis. Adm. Code BURNETT <br /> STATE SANITAR PERMIT# <br /> 5 <br /> —Attach complete plans (to the county copy only)for the system,on paper not less than STATE PLAN I."UMBER <br /> UMBER <br /> 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOq VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> KATHY ROMEISER SW'/4 NE Y4, S 9 T 39 N, R 14 <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISIO NAME <br /> 3311 33rd AVE. SO. NA NA '24-3109-0290 <br /> CITY,STATEZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> MINEAPOLIS,MN 55406 TOWN OF: RUSK BENOTT LAKE <br /> VILLAGE: <br /> II. 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.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 F <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 Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. E Conventional b. El Alternative c El Experimental <br /> 2. a. ❑System- b. ❑ Holding c.L1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. 0 IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ©See a e Bed b. ❑ Seepage Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> <3 410 410 96. 2 Feet P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Stee� Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 750 750 1 WIESER' S OC ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.�i <br /> Plumber's Name(Print): Plumber's Signature (No Stamps) MP/MPRSW No.: Bu iness Phone Number: <br /> ARLYN J. HELM — <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> P.O.BOX 71 SPOONER WI 54801 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> MELVIN J. FERGUSON <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Numb r: <br /> P.O.BOX 71 SPOONER WI — <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee I Groundwater ate Issuing ent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial Go SurchargeFee <br /> Adverse Determination "" •V l.' <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 />