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eaveseeni/ wssconsi^ APPLICATION FOR SANITARY PERMIT <br /> U D I L H R (PLB 67) Burnett <br /> COUNTY <br /> oecan..nenraF UNIFORM SANITARY PERMIT # <br /> inwsiwy,cweawsriumanr>Ecanons 7'717/ /� //�(/L' 7} <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Code for the system, on paper not less than 8%x 11 inches in size. 7 ) <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Gerald C. Olson 696 South Pine <br /> PROPERTY LOCATION MXZXX <br /> SE 1/4 SE 1/4, S 33 , T39, N, R 19 c 7 KX99- <br /> ft3�W TOWN OF: West Marshland <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> na na na Ferry Road na <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms. 2 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> FX1 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 /> J 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 790 1 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <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 /> if, <br /> 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 /> 2 410 420 <br /> © Private ❑ Joint [I] Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print): Signa re: MP/MPRSW No.: Phone Number: <br /> Donald Daniels MP 330 (715 463 2333 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren, WI 54872 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signat of Issuing Agent: Fee: 0 Date: <br /> � / ❑ Disapproved <br /> n;— N•gj5—�� EJ Owner Given Initial <br /> ,�/ / Approved Adverse Determination <br /> ason for Disapproval <br /> Alternate course(s)of Action Available: <br /> DILHR Sao6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />