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ILHFI SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05, Wis. Adm. Code Burnett <br /> STATE SAN ITARV ERM IT# <br /> q a5 13 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8% x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> Lloyd Neumann SW '/4 NE X4, S 6 T 40 , N, R 14 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> St. Rt. 4 Box 294A na na na <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> DanburyWI 54020 ER TowN OF: Scott- 1(�elhar Rd. <br /> VILLAGE <br /> It. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 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. x❑ 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 Agreement 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. seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 2 410 420 97.15 Feet x❑Private ❑Joint ❑ Public <br /> VI. TANK CAPACITYin gallons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks I Tanks structed <br /> Septic Tank or Holdin Tank750 -- 750 1 TMC Tnc. ❑ <br /> Lift Pum Tank/Si hon Chamber El ❑ <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:( Stamps)/J MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels 2v MP 330 715 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Boy. 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 Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial 6 n./^ S ch; e <br /> Adverse Determination �() lJ`J OI <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBO-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Ori mal to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />