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7- m`2 SANITARY PERMIT APPLICATION COUNTY <br /> DILIn accord with ILHR 83.05,Wis.Adm.Code <br /> Burnett <br /> STAT ANITARY PE IT# 1-2830 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ( t 1 <br /> 8'%x11inches insize. ❑ xkifrevision topeviousapplication <br /> -See reverse side for instructions for completing this application. STAT AN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. GL 3 na <br /> PROPVE�T01'r%Wnne & PROPERTY LOCATION <br /> Robert Boyer '/4 %, S 4 T 8 , N, R 15 <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 9408 Park Hunt Court na a <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Springfield, VA 1 22153 0 440-8651 na <br /> I. TYPE OF BUILDING: (Check one) Cl CITY NEAREST ROAD <br /> I <br /> ❑ $tatBOWned I7 VILLAGE: <br /> J4 XQNN OFLaFollette Fosmo Rd. <br /> ❑ Public ❑1 or 2 Fam.Dwelling-#of bedrooms PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 014-2204-02-200 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. Q New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ® Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEMELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 410 1 420 1 .4 4 1 94,10 Feet 97 .10 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank 75n 1XNC !no <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu ber's Signature:(No Stamp's) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 715 49-5533 <br /> Plumber's Address(street,City,State,Zip Code): <br /> Box 316 Siren WI 54872 <br /> IX.,COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sa nary Permit Fee(Includes Groundwater Date Issued ignature(No mps) <br /> Suronerge Fee) <br /> Approved ❑ Owner Given Initial f��. <br /> A v rmin lid Il o <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-5398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />