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(�, u SANITARY PERMIT APPLICATION COUNTY <br /> LI DILHR In accord with ILHR 83.05,Wis.Adm.Code BURNETT <br /> STATE SANITARYP MIT# <br /> iiya3 <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> NORBERT WALLENTINY NE'% SW ''/4, S 13 T 40 N, R 14 VPAM <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> STAR ROUTE BOX 303 NA NA NA <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> SPOONER, WI 548015d <br /> VILLAGE : SCOTT MID M KINZI <br /> II. 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. [:� New b. ® Replacement c. ❑Replacement of d. ❑ Reconnection of e.❑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 /> L <br /> 1. a. iConventional 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. LgSee a e Bed b. ❑seepage Trench c. 0 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 /> <3 410 410 94.9 Feet QPrivate ❑Joint El Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Li El <br /> Septic Tank or Holdin TankElElLift Pum Tank/Siphon Chamber El E] ❑ ❑ ❑ <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 Si nature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> ARLYN J. HELM 715) 635-7595 <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 Tester(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 715 ) 6-35-7595 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater r5awe Issuing Agent Signature(No Stamps) <br /> A roved �{. Surcharge Fee <br /> pp Owner Given Initial \y{, ftf\ �ff�D e �_/I <br /> Adverse Determination W UlJ IJIJ VP J (X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6396(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />