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DILHR SANITARY PERMIT APPLICATION NTY <br /> DG <br /> In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> STATE SANITARY P MIT# r/ <br /> �r 5 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8Yz x 11 inches in size. S88-20174 <br /> -See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FO VARIANCE ❑YES © NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Bob Margo SE '% SW %, S 13 T 39 , N, R14W 9(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 1866 Merrill St. GL1 <br /> CITY,STATE ZIP CODE PHONE NUMBER Q CITY NEAREST F CAD,LAKE OR LANDMARK <br /> Roseville MN. 5511 612 28-5725 14ToLwL AGoE Rusk <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. ❑X 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. ❑Conventional b. Q Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. Q 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. ❑Seepage Trench C. ❑ 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 /> Feet ®P ivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK n allons Total #ot Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tan k or Ho I d i ngTank 20001 12000 1 ITMC Inc. ❑ <br /> Lift Pump Tank/Siphon Chamber I I i I L I Ll ❑ <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 Signature:(No <br /> S/anmps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 15 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Box W Siren Wi. 54872 same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan Daniels 343 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number <br /> Box W- Siren, Wi 54872 715 349-5533 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing gent Si nature(No Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee <br /> Adverse Determination <br /> • X5.60 (0-01 <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 />