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D I L H R APPLICATION FOR SANITARY PERMIT <br /> Burnett COUNTY <br /> (PLB 67) <br /> oERRnTmEmor UNIFORM SA IT ITARY PER # <br /> RBOR 6 TR REIRTIO E 7 9eif/ y <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8Y x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Laurel Gardin 21()F rrAqf-.wnod l.nnp Keokuk IA 52612 <br /> PROPERTY LOCATION 7(XQCOC <br /> GL6 1/q 1/4, S 21 , T38, N, R 17 F (or) W TOW Daniels <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> NA NA NA Dunh m Lake <br /> TYPE OF BUILDING OR USE SERVED <br /> a 1 or 2 Family Number of Bedrooms: 2 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> a 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 /> EA 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 750 1 x <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: TMC <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift 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 /> 3 415 420 ❑x Private ❑ Joint ❑ 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): Signature: MP/MPRSW No.: Phone Number: <br /> Donald Daniels 1 330 ( 715 )463-2333 <br /> Plumber's Address: Name of Designer: <br /> Box W, Siren, WI 54872 Same <br /> COUNTY/DEPARTMENT USE ONLY <br /> 60 <br /> S _T <br /> ig u of Issuin em: Fee: Date: L1 Disapproved <br /> El Owner Given Initial <br /> '0 Approved Adverse Determination <br /> ason for Disapproval: <br /> Alternate coursels)of Action Available: <br /> DILHR-Sao-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />