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SANITARY PERMIT APPLICATION COUNTY <br /> DILHR In accord with ILHR 83.05,Wis. Adm. Code BURNETT <br /> STATE SANITARYP MIT# <br /> 13C) <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN 1.1 N BER <br /> 8'/s x 11 inches in size. 8706062 <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> iRODNEY STAPLES SE 1/4 NE '/4, S 33 T4.0 , N, R 15 VV <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> ROUTE it 1 NA NA NA <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> VTEBSTF.R, -VI 5 893 � VILLAGE: JACKSON 1 3/4- MI EAST H111Y A <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. [K 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 Agreement 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.91 Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ❑X Seepage Bed b. ❑Seepage Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): lI�� <br /> 95.6 Feet LAS Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in alions Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic App. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1000 fo00 1 1 WIESER'S M= ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 1 75q 750 1 1 WIESER'S ❑ ❑ Li ❑ <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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> ARLYN J. HELM 3360 715 35-7595 <br /> Plumber's Address(Street,City,State,Zip Co--,. Name of Designer: <br /> P.O.BOX 71, SPOONER W1 54801 SAME <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> SAME 3331 <br /> CST's ADDRESS(Street,City.State,Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee I Groundwater ate Issuin gent Signature(No Stamps) <br /> Approved F-1OwnerGiven Initial 11 I C.An rcha:g/eFF�ee \ � <br /> Adverse Determination /'fJ vV lJV _Nt/I <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 />