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SANITARY PERMIT APPLICATION COUNTY BURNETT <br /> DJLHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY P RMIT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> sya53 <br /> 8+/iX 111DChe31n size. ❑ Ch(eck if revision 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 D. PETERSON SE +/4 SE +/4, S 5 T39 , N, R 14 E�fpf) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CTY RD H NA NA <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> WEBSTER, WI 54893 <br /> ROAD <br /> IL TYPE OF BUILDING: (Check one) ❑ State Owned CITY :RUSK N CO E HWY H <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 1— RR�EL Ax u BER( <br /> III. BUILDING USE: (If building type is public,check all that apply) �'�. 31 D 5 -pZ,000 <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 0 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 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.tt.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 150 165 165 <3 94.7 Feet 96.7 Feet <br /> VII. TANK CAPACITY Site <br /> in allc 8 Total #of Prefab. Fiber- Exper. <br /> INFORMATION New iatin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 75U 1 WIESER' S <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of th onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu bar's Signature:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> MELVIN J. FERGUSON 3393 7595 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> P.O.BOX 71 , SPOONER, WI 54801 <br /> IX COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sani ry Permit"a(Includes Groundwater Date Issued Is in Agent Sig re(No Stamps) <br /> �. <br /> Approved [] Owner <br /> Fee)Given Initial 'h� R}-� <br /> Adverse rmin i n 11.1 Vt� O <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/38) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />