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APPLICATION FOR SANITARY PERMIT <br /> Ez:DILHR Burnett COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT # <br /> RT VLNOF ^ / -/ 11STRV,LRBOR6NVTRr1RELRT1Of15 <O U097 \ II /� 2/ <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8Yzx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Phil Knudson Rt. 2 Box 259 Stanchfield, MN 55080 <br /> PROPERTY LOCATION XXM <br /> NW 1/4 NWI/4, S 33 , T 39N R 19 ExO) W TOW F West Marshland <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> na na na Bistram Rd. - Fire I#27313 8407644 <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: 2 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ExJ 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 /> ❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit [x] 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 toConcrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> 2000 <br /> Manufacturer: TMC ino- Pnskin, WT <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 Feetl: <br /> na na na © 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): Sig tore: MP6101m[IX: Phone Number: <br /> Donald Daniels 330 (715 463 2333 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren, WI 54872 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> pa <br /> yt C�� /d _�� _�// A ❑ Owner Given Initial <br /> Yl�a 7 pproved Adverse Determination <br /> ason for Disapproval ,e� <br /> Alternate coursels)of Action Available: <br /> DILHR-SBD 6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner,Plumber <br />