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SANITARY PERMIT APPLICATION COUNTY <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm. Code BURNETT <br /> STATE SANITARY PERMIT# 158428 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than (15718) <br /> 8'%x 11 inches in size. ❑ Check If revision to previous application <br /> —See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S91-20428 <br /> PROPERTY OWNER 1PROPERTY <br /> J £ ST� DQo,.151�1 0 Ty1 , N, R E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS 2 G c�V . L1sCITY,STATE ZIP CODE PHONE NUMBER <br /> LJ NEAREST ROAD <br /> II. TYPE OF BUI DING: (Check one) ❑State Owned Co. Rd. A <br /> it 40W OF' <br /> ❑ Public or 2 Fam.Dwelling-#of bedrooms <br /> III. BUILDING USE: (If building type is public,check all that apply) 28-4120-01-300 <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. ElReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) X❑ A Sanitary Permit was previously issued. Permit# 151381 Date Issued 4-24-91 <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑ Seepage Bed 2 Mound 30 El SpecifyType 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 /> 3p REOUIR (sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> � 6-Z_ ! '7 ' <br /> + L—Feet oU�YS Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank <br /> Lift Pump Tank/Siphon Chamber,_ �M <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> tuber's Name(Print): PIjUlybis Signature o mps) MP/MPRSW No.: Business Phone Number: <br /> Z4 S - <br /> Plumber's Address is r ',City,State,Zip Cod ): <br /> IX. COUNTY/DEPARTM NT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Dale ssue Issuing Agent Signature(No Stamps) <br /> X A roved surcharge Fee) / <br /> ❑ pp ❑ Owner Given $170.00 7-8-91 <br /> Adverse De in tin I 'j <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> Garage location affected the initial system location and soils in alternate area. A new <br /> perc and sanitary system was called for as new area required a mound system. <br /> SBD-6398(formerly Plb-67)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />