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[�, ^ SANITARY PERMIT APPLICATION C UNTY <br /> LI 'LHR . In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> STATE SANITARYiRMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE TITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Dean J. Nelson WZSW '% NW 1/4, S26 T 39 , N, R 9 xFr*(InW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> na na na <br /> CITY,STATEZIP CODE PHONE NUMBER CITY NEAREST OAD,LAKE OR LANDMARK <br /> VILLAGrantsburg, WI 54840 715 463-2889 r3 J&jjN-E:W.Marshland Ct 'IF " & Pete Nelson Rd. <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): <br /> 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. [i] 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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. a 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. ® See a e Bed b. ❑seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 6 Feet 0 rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> iIn allons Total #of Prefab. Fiber- L <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste glass PlasTanks Tanks structed <br /> Se tic Tank or Holdin Tank 1000 1000 TMC I ❑i hon 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): MP/MPRSW No.: B siness Phone Number: <br /> Plu is Signature:(No Stamps) <br /> Donald Daniels 4 <br /> Plumber's Address(Street,City,State,Zip Codfl: Name of Designer: <br /> Box W Siren, WI 54872 sante <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan E. Daniels <br /> CST's ADDRESS(Street,City,Slate,Zip Code) Phone Numl er: <br /> Box W Siren, W <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sa itary Permit Fee Groundwater Mate Issu Agent lure(No Stamps) <br /> Approved ❑ Owner Given Initial (/�y,,1 �41� ,Syy{1ChargeAFreee ,�7n�– <br /> AdverseDetermination 6D-OrD "'3S•VV �_—" <br /> W15144- <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 />