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W15CO^S1^ APPLICATION FOR SANITARY PERMIT <br /> D I L H R Burnett -COUNTY <br /> (PLB 67) UNIFORM SANITARY PE MIT <br /> oEppaT <br /> TSC <br /> pUTRVLA,LA5Ofi6MUTAn N6LPT10r15 <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8/zx 11 inc/hese in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Steven Durand 16980 200th St. E. Hasting, MN 55033 <br /> PROPERTY LOCATION $X= <br /> N} ?qty NEA/4, S 33 , T 38, N, R 15xE3jrrJ W ow LaFollette <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST R AD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> na na na St les Rd. na <br /> TYPE OF BUILDING OR USE SERVED <br /> �� 1 or 2 Family Number of Bedrooms. 2 U Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> New 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 /> EX Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> �l 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 <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity 750 1 X <br /> Lift PumpTank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: TMC Inc. POskin, WI <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 I Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WgTER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> 3 410 1 420 ® Private ❑ 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): MP*k-M /7(*i.: I Phone Number: <br /> Donald Daniels 330 715-4)63-2333 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren, WI 54872 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ature of Issuing Agent: 1 ❑ Disapproved <br /> q"� ❑ Owner Given Initial <br /> APProved Adverse Determination <br /> eason for Disapproval: .0 J <br /> Alternate course(s)of Action Available: <br /> DI LHR SBD 6398 (R. 5/821 DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />