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SANITARY PERMIT APPLICATION co iNTY <br /> � DILHR In accord with ILHR 83.05,Wis. Adm. Code Burnett <br /> io.,, ST TE SANITARYRMIT <br /> 1 13 <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than ST TE PLAN I. .NUMBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE rITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES �L] NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> Bruce Teigen NE '/4 NE %4, S 36 T38 , N, R 8 xW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> Grantsbur WI 54872 715_ 63-55 ❑ VILLAGE Wood River Little Wood 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. x❑ 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 AgreernE 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. KI Seepage Bed b. ❑Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 3 620 624 91 .92 Feet ®P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank1000 -- 1000 1 TMC Inc. KI El <br /> Lift Pum Tank/Si hon Chamber ❑ ❑ ❑ ❑ <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): Plu is Signature:(No amps) f MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 15 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Box W Siren, WI 54872 same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Ken Strabel 3322 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> Rt. 2 Webster, WI 54893 715 349-2990 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Ise ng gent Si nature Stamps) <br /> Approved ❑ Owner Given Initial Surcharge F(g�ere�� QQ <br /> Adverse Determination � aS't� �y1' "—UU <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 />