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(�, SANITARY PERMIT APPLICATION COUNTY <br /> 1 l 01LHR In accord with ILHR 83.05,Wis. Adm. Code BURNETT <br /> STATE SANITARY PERMIT# <br /> ' f <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D. N UMBER <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 El YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> WILBUR SLOUGH NW '/4 SW %, S 13 T 39, N, R 14 YMYW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> RT #1 BOX 1132 NA NA NA <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> SPOONER, WI 54801 VILLAGE : RUSK LISETT LAKE <br /> 11. 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.® Replacement c. D 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. 5d 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. ® See a e Bed b. ❑Seepage Trench c. 0 Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5=ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> <3 615 615 OPrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in all Total #ot Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Se ticTankor Holding Tank 10001 10001 1 WIESER'S ❑❑ F-1 ❑❑ El F-1 F] <br /> Lift Pum Tank/Siphon Chamber <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): Plumber's ignature:(No Stamp MP/MPRSW No.: Business Phone Number. <br /> ARLYN J. HELM 715 635-7595 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> P.O.BOX 71 , SPOONER, WI 54801 <br /> Vlll. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> MELVIN J. FERGUSON 3669 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> P.O.BOX 71 SPOONER WI 54801 ( 715 ) 635-7595 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> L] Disapproved Sa itary Permit Fee Groundwater ate ssuing A ent Signature(No Stamps) <br /> Approvetl S ch Fee - <br /> ❑ Owner Given Initial �X',�r�� <br /> Adverse Determination <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,Plumber <br />