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SANITARY PERMIT APPLICATION COUNTY <br /> �DILHR In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> ommmo STATE SANITARY P�q MIT�/I�+`I`7I( <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ �kl to <br /> 8%x 11 Inches In size. Ch drev Sion previous application <br /> —See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S89-20383 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Steve KlugGL1 '/a ''/a, S 2 T N, R 18 } (Or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 844 17th Av S 10 NA <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> M 40 612 722-0400 Pine Lake lots <br /> If. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE Pine Lake Road <br /> ❑ Public ❑{ 1 or 2 Fam. Dwelling-#of bedrooms L TAX NUMBER(S) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 034-9015-02000 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 11Z New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ SpecityType 41 %❑ Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PERDAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #oi Prefab. Fiber- Exper. <br /> INFORMATION New iatln Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank 2000 120001 TMC Inc. <br /> Litt Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plum Signat�oStamga) MP/MPRSWNo.: Business Phone Number: <br /> Donald Daniels 715 349-5533 <br /> Plumber's Address(Street,City,State,zip Code): <br /> 24064 Hwy 39 P-0- Box W Siren, Wi 54872 <br /> X. COUNTY/DEPARTMENT USE ONLY <br /> Ej Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Issuing Agent Signature(No Stamps) <br /> /��Surcharge Fee) q <br /> Approved ❑ ownerGiveninitial <br /> Allvense,Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />