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APPLICATION FOR SANITARY PERMIT <br /> D I L H R Burnett couNTv <br /> e�oeaRRmlenT OF (PLB 67) UNIFORM SANITARY PERMIT # <br /> InOUSTRV,LRBOp 6MUTRn RELRTIOnS <br /> 3 Y �'. /1246 ) <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 /> Mike Eizeland 2914 36th Ave. N.E. Minneapolis, MN 55418 <br /> PFffE�TY LOCATION etry: <br /> 1/4 1/4, S 34 , T 38 N, R 181xia:W W TOWN OF: Wood River <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> 1 na na jAkermark Rd. on Wood Lake 8501368 <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: /�/ ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> N New System ❑ Tank Replacement ❑ Repair <br /> X Replacement Soil Absorption System ss pR lly ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> ❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit FY1- 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 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity moo x <br /> Manufacturer: TMC Inc. <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 Feet): PROPOSED (Square Feet): <br /> na na <br /> na ® Private ❑ Joint 1:1 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 /> Donald Daniels IMP 330 715 )463 2333 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren, WI 54872 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: <br /> d O ❑ Disapproved <br /> Ld �� n-L �/ (J �� '/�' ! ��✓ t.Approved ❑ Owner Given Initial <br /> Adverse Determination <br /> Re son for Disapproval ,fJ <br /> Alternate counsels)of Action Available: <br /> DILHR-SBO-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />