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^ APPLICATION FOR SANITARY PERMIT <br /> D I L H R BURNETT COUNTY <br /> (PLB 67) UNIFORM SA ITARY PER T # <br /> OEPRRTTEnT OF <br /> - IIIWSTRV.LR8(M611UMR RELRT10nS /1r <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> ROBERT JACK 9008 Hurnholt- Ayp Nn - Mplq Minn SSS o <br /> PROPERTY LOCATION CITY: <br /> VILLAGE: <br /> NW 1/4 SE 1/4, S 14 , T 4p N, R 17 E (or) W TOWN OF: UNION <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> ONE <br /> TYPE OF BUILDING OR USE SERVED <br /> ,�xi,(�E 2 Family Number of Bedrooms: TWO ❑ Public (Specify): <br /> TH�ISPERMIT IS FOR A: <br /> JU"w 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 /> xIFA 366e`paye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ 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 Tanks Concrete Constructed <br /> Septic Tank Capacity 750 XXXXXX X <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> ManufacturerTri—State—Poskins Wis . <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 Feetl: PROPOSED (Square Feet, <br /> 4 410 432 U"Waxe ❑ 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): Sign re: • MP/MPRSW No.: Phone Number: <br /> Joe M. Jamison MP731 (7151349-5622 <br /> Plumber's Address: Name of Designer: <br /> Box 369—Siren Wis . /54872 J .Jamison <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig re of Issum �g/ernt: Alf ee: Date: ❑ Disapproved <br /> Approved ElOwner Given Initial <br /> Adverse Determination <br /> son for Disapprove <br /> Alternate course(s)of Action Available: <br /> DI LHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />