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I SANITARY PERMIT APPLICATION <br />COUNTY <br />U • DIL,�H In accord with ILHR 83.05, Wis. Adm. Code <br />Burnett <br />STATE ANIT RY ERMIT#t <br />"�..m ..r �..� <br />`i <br />—Attach complete plans (to the county copy only) for the system, on paper not less than <br />STATE PLAN I.D. NUMBER <br />8'/2 x 11 inches in size. <br />�3 r7aQO3 <br />—See reverse side for instructions for completing this application. <br />PETITION <br />❑ ®NO <br />1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. <br />FOR VARIANCE YES <br />PROPERTY OWNER <br />PROPERTY LOCATION <br />Penny King Gull Lake Resort <br />GL 1'/4 '/4, S 2 T 4 0 , N, R 16 xEXiDx) W <br />PROPERTY OWNER'S MAILING ADDRESS <br />LOT NUMBER <br />BLOCK NUMBER SUBDIVISION NAME <br />Rt. 1 Box 430 <br />na <br />na na <br />CITY, STATE <br />ZIP CODE <br />PHONE NUMBER <br />71 CITY NEAREST ROAD, LAKE OR LANDMARK <br />E3 VILLAGE <br />Danbury, WI <br />54830 <br />[XI TOWN : Oakland Gull Lake <br />I1. 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 />1. a. Q 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. 0 seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br />2. PERCOLATION RATE <br />3. ABSORPTION AREA4. <br />ABSORPTION AREA <br />5. SYSTEM ELEVATION <br />6. WATER SUPPLY: <br />(Minutes per inch): <br />REQUIRED (Square Feet): <br />PROPOSED (Square Feet): <br />3 <br />410 <br />420 <br />92.50 Feet <br />❑ Private ® Joint ❑ Public <br />VI. TANK <br />INFORMATION <br />CAPACITY <br />in gallons <br />Total <br />Gallons <br />## ofPrefab. <br />Tanks <br />Manufacturer's Name <br />Concrete <br />Site <br />Con- <br />Steel <br />Fiber- <br />glass <br />Plastic <br />Exper. <br />App <br />New xisting <br />Tanks Tanks <br />structed <br />Septic Tank or Holding Tank <br />750 <br />❑❑ <br />❑ <br />❑ <br />❑ <br />Lift Pum Tank/Siphon Chamber <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <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): <br />Plumber's Signature: (No Stamps) <br />MP/MPRSW No.: <br />Business Phone Number: <br />Donald Daniels <br />MPW 330 <br />715 349-5533 <br />Plumber's Address (Street, City, State, Zip Code): <br />Name of Designer: <br />Box W, Siren, WI 54872 <br />Same <br />VIII. SOIL TEST INFORMATION <br />Certified Soil Tester (CST) Name CST # <br />Joan DAniels 3431 <br />CST's ADDRESS (Street, City, State, Zip Code) Phone Number: <br />Box W, Siren, WI 54872 715 349-5533 <br />.1);. COUNTY/DEPARTMENT USE ONLY <br />❑ Disapproved <br />itary Permit Fee <br />Groundwater <br />ate <br />Issuin gent Signature (No Stamps) <br />Approved <br />F-1 owner Given Initial <br />3g(�-M <br />S r-^c�harge//��F--eee <br />�- -35,OD(J�J�/ <br />�j <br />(fes <br />/ IaL-L., <br />Advers <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 />