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SANITARY PERMIT APPLICATION COUNTY <br /> fl DILHRBurnett <br /> In accord with ILHR 83.05,Wis. Adm. Cede STATE SANITARY PERMI <br /> T <br /> mommms 81177 I- �� <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMB <br /> 816 x 11 inches in size. 8702046 <br /> -See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Frank Presseller GL 1 '/4 /4, S 6 T 39 , N, R 16 xfx*Or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 3651 Van Buren St. N.E. na na na <br /> CITY,STATE ZIP CODE PHONE NUMBER [I CITY[I : NEAREST ROAD,LAKE OR LANDMARK <br /> Minnea alis MN 55418 VILLAGEMeenon Yellow Lake <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify): <br /> 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ❑ New b. x❑ 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. ❑Conventional b. x❑Alternative G. ❑ Experimental <br /> 2. a. ❑System- b. x❑ 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. ❑See a is Trench c. ❑ See a e 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 /> Feet ❑Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site Fiber- <br /> Ingallons Total #of Prefab. Exper. <br /> INFORMATION Manufacturer's Name Con- Steel Plastic <br /> New xisting Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1 - 2000 1 TMC Inc. ❑ x ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ <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): PI mber'sSure:(yq Stamps MP/MPRSW No.: Business Phone Number: <br /> Donald DAniels J(pfj� MP 0 f715 463-2333 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> P.O. Box W Siren WI 54872 same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan Daniels 1411 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> P-0. Box W Siren WI 54872 715 ) 463-2333 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> F-1 Disapprovetl Sanitary Per mit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> S rcharge Fee _ <br /> Approved ❑ Owner Given Initial S/�-rl <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 />