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SANITARY PERMIT APPLICATION COUNTY <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> Burnett <br /> �•�� STATE SANITARY MIT#,a07a <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than Ca� <br /> 8'%x 11 inches in size. ❑ chwl. revisbn 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. Sq-3 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Robert Rutledge L 3 Y4 Y., S 6 T38 , N, R 15 /9/(6r W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1'� <br /> 24785 Owl Lake Rd na <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Webster WI 54893 715 349-764 -M CSm V, I P, l61q <br /> Li CITY Owl LD <br /> II. TYPE OF BUILDING: (Check one) ❑ 10State Owned VILLAGE: LaFollette akeRd <br /> ❑ Public 01 or 2 Fam.Dwelling-#of bedrooms Z R AX NU R( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) f � �p� Oc;;'O� ' <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. ® 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 300 REQUIRED(sq.ft.) PROPOSED(sq.ff.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 375 376 .8 <,3 97.45 Feet 100.45Feet <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 Holdino Tank lood -- <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): Plumber's Signature:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels p( �eeaQiG� MP 330 715 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> PO BOX 316 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved 1 Sanitary Permit Fee(Includes Groundwater a e ssue Issuing A e ignat (N ) <br /> PP -.1+ I��as, <br /> Fee) <br /> Approved EI Given Initial ��''yy l <br /> Adve Determin ion <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />