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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> Burnett <br /> STATE SftNITARY�RMIT#I f/_i/]-Attach complete plans(to the county copy only)for the system,on paper not less than y� `U /8%x 11 inches in size. ❑ U(Check i revieloo previous application <br /> —See reverse side for Ir1StrUCSIODS for COmpl@flog this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. 8 _ <br /> PROPERTY OWNER PROPERTY LOCATION <br /> First Wis . Bank David Huff AIF 1/4 SW 1/4, S 2 6 T 38 , N, R18 )t (Or)s <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> P .O . Box 69 1 k 2 <br /> CITY,STATE ZIP CODE I PHONE NUMBER SUBDIVISION N{tM OR CSM NUMBER <br /> Grantsburg , Wi . 54840 715 63-5301 /�1vll <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned 0 VILLAGETaood River County "M" <br /> ❑ Public 1 or 2 Fam.Dwellings of bedrooms 6 91 TOWN PARCEL TAX NUMBER(S) <br /> Ill. BUILDING USE: (if building type is public,check all that apply) 4°"`' 'a 5�� _ o yyoo <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. U 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 ❑ 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 2.ABSORP.AREA 13.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min../'finch) r1 ELEVATION <br /> l V� <br /> -750 0 ( `J 0 f o� 19, 100'40 Feet JW,40 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdino Tank 1000W1PSr <br /> Lift Pum Tank/Siphon Chamber 1000 1000 1 Wieser P. <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(NN/o�pta�mps) MP/MPRSW No.: Business Phone Number: <br /> Donald. Daniels (N`"' " "- " "Ice� MP 130 715 340-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> P.O. Box W Siren Wi, 54872 <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater a essue Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial I V Cc surcharge Fee) 757 <br /> �� j <br /> Adverse Determination /li l�lJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />