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SANITARY PERMIT APPLICATION COLINTY <br /> C 131LHR In accord with lLHR83.05,Wis.Adm.Code Burnett <br /> s STATESANITARYP RMIT# <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PEITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION I <br /> A . Searles & Son ( Craig Root home ) L4 '% '/4, S15 T38 , N, R15 )X(rX))N <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> Hertel , WI 54845 na na na <br /> CITY,STATE ZIP CODE PHONE NUMBER ED CITY NEAREST ROAD,LAKE OR LANDMARK <br /> 715 1349-326 7k TOWN OF 7 VILLAGE LaFollette Cranbe ry Rd. <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.0 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. Q Seepage Bed b. ❑See a e Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 98.25 Private ❑Joint ❑ Public <br /> 3 615 630 Feet <br /> CAPACITY <br /> VI. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xi"ting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1000 -- 10 1 Wieser L-1Lift Pum Tank/Siphon Chamber 0 00 1 comb, Septic/ um ❑ ❑ ❑ 1 ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans <br /> Plumber's Name(Print): Plum is Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> MP 330 15 49-5533 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Box W Siren, WI 54872 same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan E. Daniels 3431 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> Box W Siren, WI 54872 715 349-5533 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I S nitary Permit Fee I Groundwater ate ( Issuing Agent Si nature(No Stamps) <br /> Approved ❑ Owner Given Initial (X�)1 S rcharge(Fe�e �Cr00 <br /> Adverse Determination r R 'J V ltD•�" <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumbed <br />