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SANITARY PERMIT APPLICATION GG NTY <br /> DILHR In accord with ILHR 83.05,Wis. Adm.CodeBURNETT <br /> ST TE SANITARY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.N BER <br /> 8'%x 11 inches in size. 87064.4.3 <br /> —See reverse side for instructions for completing this application. PE ITION In'� <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FO VARIANCE tX1 YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> FRED LA TULIP S-9 '/a SW /4, S 24 T4.0 , N, R 14 VtWW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER I BLOCK NUMBER SUBDIVISI N NAME <br /> STAR RT BOR 317 NA NA NA <br /> CITY,STATE ZIP CODE PHONE NUMBER I CITY : NEAREST F CAD,LAKE OR LANDMARK <br /> SPOONE3 NI 4.801 RH TOWN OF:O VILLAGE: SCOTT LAKE MC KENZIE <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. ❑ 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 AgreeME 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. [Z seepage Bed b. ❑Seepa e Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): [�II <br /> 1 375 375 99.23 Feet It F rivate ❑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 Hold in Tank 120 1200 1 ',''7 E ' 1 r ❑ ❑ <br /> Lift Pum Tank/Siphon Chamber o n 1IIE Er S ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan <br /> Plumber's Name(Print): MP/MPRSW No.: B siness Phone Number: <br /> Plum 's Si ature:(No <br /> ARLYN J. HFLM 3360 JA 715 635-7595 <br /> Plumber's Address(Street,City,State,Zip Code): IName of Designer: <br /> p11 54801SAME <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name sACST# <br /> n�E 331 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issui gA ntS nature(N St ps) <br /> / 1 S o charge Fee n <br /> Approved ❑ Owner eDetermin (I �S.-,�-7., L 6 <br /> Adverse Determination T V l,� i -O <br /> 1171 <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb£7)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumbe <br />