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APPLICATION FOR SANITARY PERMIT <br /> � D I L H R Burnett <br /> BOUNTY <br /> oERRRTmEnT ov (PLB 67) UNIFORM SANITARY PERM.T # <br /> a� �nWSTFV,LABOFSHumRnRELRnOns <br /> /ay6y <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 81/:x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Tom Drews 4026 NE 6th St. Columbia Heights, MN 55421 <br /> PROPERTY LOCATION AR-ky: <br /> NE 1/4 SW 1/4, S 27 T37, N, R 18 :EXOM;W mkIll TOWN OF: Trade Lake <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> na na na Round Lake I na <br /> TYPE OF BUILDING OR USE SERVED <br /> ix) 1 or 2 Family Number of Bedrooms: 2 Tj Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> a 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 /> J Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> ❑ 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 Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity 750 1 x <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: TMC Inc. <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 Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square %etl: PROPOSED (Square Feet): <br /> 3 415 420 ® 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): Signa r r MP/MPRSW No.: Phone Number: <br /> Donald Daniels MP 330 (715 ) 463 2333 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren, WI 54872 1same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa a of Issuing ant: Fee: Date: <br /> El Disapproved <br /> �o <br /> ❑ Owner Given Initial <br /> , Approved Adverse Determination <br /> son for Disapproval: <br /> Alternate counsels)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />