Laserfiche WebLink
- d SANITARY PERMIT APPLICATION <br /> COUNTY <br /> In accord with ILHR 83.05,Wis. Adm. Code BURNETT <br /> STATE$ANITAR)(PERMIT#;/ %%/� <br /> –Attach complete plans(to the county copy only)for the system, on paper not less than <br /> 5-,-0'4,:) L'Cri-y /'I <br /> 8'%x 11 inches in size. ❑ Check if revis}6n to 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 /> TKITH JOFT'N ,N SE 'A Y./ 1% S 25 T 40 <br /> N, R 1 /44,6►4(Vy <br /> PROPE,RTY OWNER'S MAILING ADDRESSLOT# BLOCK# <br /> 1615 23rd AVE NW, ,( 0 oY .-4 <br /> 2 N/A <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION)NAME OR CSM NUMBER <br /> IS ET BRIGHTON, IVIN 55112 ( 612r636477"3 N/A <br /> II. TYPE OF BUILDING: (Check one) ❑ CITY NEAREST ROAD <br /> [7 State Owned C VILLAGE SCOTT POINTE PRIVATE <br /> TOWN OF <br /> Public ®1 or 2 Fam. Dwelling–a of bedrooms 2 PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) )Sl Li)( 1---;-- <br /> 1-- — J—3.__/i/ ) <br /> 1 ❑ Apt/Condo 1 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 I I 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. 1 1 New2. X Replacement 3. Replacement of 4. Reconnection of 5.1 1 Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) 1 1 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 X1 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 1 1 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 00 4.80 4.80 .625 {3 92.7 Feet 95.2 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total ##ofManufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New Existing Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or olantylrartk 1000 1000 1 SKA'i'rr ❑ E. ❑ ❑ ❑ ❑ <br /> Lift PumpTank/3ipherrOhamber 600 600 COMBINATION ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibi it"y for installation 1the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signatu :(No Stamps) WF/MPRSW No.: Business Phone Number: <br /> TEL J. },RGU ,ON3393 ( 715-)635-74.82 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> HCR 59 BOX 4.78d SPOONER, /,1I 54801 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ;,4, ❑ Disapproved Sanitary Permit F. <br /> ee(Includes Groundwater <br /> rcharge Fee) Date Issued Issuing Agent Signature(No Stamps) <br /> pproved ❑ Owner Given Initial _ �; _ 1 r � / �(i 2 ',s _53. <br /> Adverse Determination 1 ( -''� ���* <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: ` ' <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />