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SANITARY PERMIT APPLICATION <br /> �1111A.�I In accord with ILHR 83.05,Wis.Adm.Code co NTv <br /> BURNETT <br /> ST TE SCANITA.Y PER IT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than TES Jc/�,� )S yCI <br /> 8'k x 11 Inches In size. Check if revis on to previous application <br /> —See reverse side for instructions for completing this application. ST TE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTYOWNER PROPERTY LOCATION govt: . lot 5 <br /> Bob and Jean Johnson '/, %4, S 14 T 40, N R 16/5!Xof)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC K# <br /> Box 815 5 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Cumberland WI 54829 ( 715 )8220470- ISO <br /> IL TYPE OF BUILDING: (Check one) ❑State Owned Li ITYO VI AGE NEA EST ROAD <br /> I�/� Oakland Linda Lake <br /> 1:1 Public K or 2 Fam. Dwelling-#of bedrooms 1 PAR ELTAx NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) (� -q%)q —Qy -;too <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Ou door 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. TYfrPPEEtOF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. L'-1-New 2. ❑ 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 Myseepage Bed 21 ❑ Mound 30 ❑ SpecityType 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 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 150 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 215 12 x 16 =21 <br /> 5 9 a•3 7 Feet pI ,s Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank 750 750 1 1 Wieser ' s <br /> Litt Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fo nstallation of the onsite sewage syste hown on the attached p lans. <br /> Plumber's Name(Print): Z67�7 <br /> ur/e��(NoS mps P/MPRSWNo.: Business Phone Number: <br /> Richard G. Anderson lX MP 6290 715-6 5-8752 <br /> C <br /> Plumber's Address(Street,City,State,Z_pi de):548 I <br /> Spooner, W <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwaterae Issued Issuing g t at ( o mps) <br /> Approved ❑ Owner Given Initial Staebarge Fee) ryr 1� � <br /> Adverse Determination `^ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Ow er,Plumber <br />