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��LHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> STATE SANITARY P RMIT#� 5� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than C/`> JJ� <br /> 8%x 11 inches in size. ❑ check Ifrevlsb o previous application <br /> —See reverse side for instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Robert Merker GL 2 % '/4, S 1 T 40 , N. R 15 //EZ(dfllW2 <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 516 2nd Ave. E. na I na <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Durand WI 54736 715- 672-8015 na <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned O VILLAGE: Jackson Loon Lake Drive <br /> El Public R❑1 or 2 Fern. Dwelling—#of bedroom AR EL 110 IOWN <br /> TAX NUM <br /> III. BUILDING USE: (If building type is public,check all that apply) <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. X❑ 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 ® 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 3.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 16. SYSTEMELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 615 630 1 ,4 3 95.65 Feet 99.00 Feet <br /> CAPACITY VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New !sting Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdinct TankX <br /> Lift Pump Tank/Siphon Chamber <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): Plu is Signattur�e::(No ps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels 0e�/Y7/lelq- � �W✓�J MP 330 _ <br /> Plumber's Address(street,City,State,Zip Code): <br /> PO Box 316 Siren WI 54872 <br /> IY, COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater a e ss ie Isru' Agent Signe (No Stamps) <br /> Approved ❑ Owner Given Initial IJ /,�-� surcnuge Fee) <br /> Adverse oc <br /> 5• <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Pib-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />