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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> BURNETT <br /> STATE SANITAR PERMIT# C^r, <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than l�'�' f <br /> 8+%x 11 Inches In size. ❑ check If revis n to previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> KEITH MORTENSEN SE % NW y4 S 25 T 40, N, R 14//klVW <br /> PROPERTY OWNER'S MAILING ADDREs,,� LOT# BLOCK# <br /> 1615 23rd AVE NW, ,tyl;4klAti'RLF3iZU G,Y`�. 2 N/A <br /> CITY,STATE ZIP CODE PHONE NUM ER SUBDIVISIO NAME OR CSM NUMBER <br /> (N BRIGHTON, MN 55112 612 36477 N7A <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned QVILLAGE NEAREST ROAD <br /> SCOTT [NEST POINTE PRIVATE <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 21h8FLYTAhUM <br /> III. BUILDING USE: (If building type is public,check all that apply) I <br /> �)Q q <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. ❑ 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 A 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 12.ABSORP.AREA 3.ABSORP.AREA 14. LOADINGRATE j5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .625 {3 92.7 Feet 1 95.2 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons of Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tankor91:e1HierrOhember 100 1000 1 S <br /> OMBIN <br /> Litt Pum Tanta 00 00+ C <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibi ify for installation Othe onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signatu :(No Stamps) MPRSWNo.: Y( 715 <br /> siness Phone Number: <br /> MEL J. FERGUSON 3393 35-7482 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> HCR 59 BOX 478d SPOONER, WI 54801 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved ISanitary Permit Fee(Includes Groundwater Yatee ue Issuing Agent Signature(No Stamps) <br /> surcharge Fee) <br /> pproved ❑ Owner Given Initial 1 f/�. � ((� } � <br /> Adv rmination �f c _G 1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/99) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />