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(� ^ SANITARY PERMIT APPLICATION COUNTY <br /> tl DILHR In accord with ILHR 83.05,Wis.Adm.Code BURNETT <br /> O STATE SANITARY P MIT# <br /> < i <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D. MBER <br /> 8%x 11 inches in size. <br /> —See reverse side for instructions for Completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> GORDON HANSON SE %NW %, S 2 T 38, N, R 14 W, <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 2700 S. BROADWAY 14 NA OAK PARK <br /> CITY,STATE ZIP CODEPHONE NUMBER CIN NEAREST ROAD,LAKE OR LANDMARK <br /> MENOMONIE, WI 54751f kjT'oLwLNGoEFDEWEY PO <br /> If. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. IN New b. KI Replacement c. DReplacement of d.❑ Reconnection of e.0 Repair of an <br /> System System Septic Tank Only an Existing System Existing System <br /> 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. <br /> 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ®Conventional b. ❑Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ® Seepage Bed b. ❑Seepage Trench c. IJ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 5 410 410 94. 3 Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY #of Prefab. Site Fiber- Exper. <br /> in allons Total Manufacturer's Name Con- Steel Plastic <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank 750 750 1 WIESER'S ® ❑ 0 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ I ❑ ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's ' nature: o Stamp MP/MPRSW No.: Business Phone Number: <br /> ARLYN J. HELM 3360 7635-7139-9 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> P.O.BOX 71 , SPOONER, WI 54801 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tesler(CST)Name CST# <br /> MELVIN J. FERGUSON <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> P.O.BOX 71 SPOONER WI 54801 <br /> 1Y4. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee I Groundwater Pate I IssumgpAgent Signature(No Stamps) <br /> pproved ❑ rcharge Fee <br /> Owner Given initial I C11 —) <br /> Adverse Determination ��'�� <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />