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SANITARY PERMIT APPLICATION DOUN Y <br /> DILHR Burnett <br /> _ �"7 In accord with ILHR 83.05,Wis. Adm. Code STAT SANITARY RMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STAT PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PETI7 ION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FORVARIANCE ❑YES NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> Randy Carey NE '/a NE '/a, S 36 T 38 , N, R 18 xefor)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> Rt. 1 9 na a <br /> CITY,STATEZIP CODE PHONE NUMBER CITY : NEAREST ROAD,LAKE OR LANDMARK <br /> Siren, WI 54872 715 349-5608 O VILLAGE : Wood River Little W od Lake <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 'i 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.E1Repair 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 Agreemen to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. O Conventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding C.1:1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. El IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. 0 See lacie Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2, PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WA ER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 3 615 630 92. Feet ®Pri ate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. con Fiber- Expp. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete strr cted Steel glass Plastic App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> VII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): Flu er's Signatur :IN tamps) MPIMPRSW No.: Bus ness Phone Number: <br /> Donald Daniels MP 330 (715 )149-553 <br /> Plumber's Address(Street,City,State,Zip Co I 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 Phone Numb <br /> CST's ADDRESS(Street,City,State,Zip Code) <br /> Rt. 2 Webster, WI 54893 715 349-2990 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved <br /> Sanitary Fee Groundwater ate Issuing Agent Si ature(No Stamps) <br /> ^�1.JoW S charge Fee �p_ai-�1 yrcr, <br /> Approved ❑ Owner Given Initial �JT iy-n <br /> Adverse Determination v V <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> bing <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,one Copy To:Bureau of Plum ,OwnerPlumber <br /> , <br />