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(�, SANITARY PERMIT APPLICATION COUNTY <br /> L 1 ®'LHR' In accord with ILHR 83.05,Wis.Adm. Code Burnett <br /> �� — STATE SANITARY P,( RMIT# <br /> jr <br /> —Attach complete plans (to the county copy only)for the system, on paper not less than S,ATE PLAN I.D.NUMBER <br /> 8'/2 x 11 inches in size. 87-08344 <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 /> Ike Walton Lodge GL3 1/4 % S19&20 T 40 N R 16 xkxk) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> Star Rt, na Tna na <br /> CITY,STATE ZIP CODE PHONE NUMBER 77 CITY NEAREST ROAD,LAKE OR LANDMARK <br /> Danbury 511830 � ( 715 8667101 T7 TILLAGE : Oakland Yellow Lake <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR x❑ Public(Specify): Lodge <br /> III. 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. 1�1 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. ❑ Seepage 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 /> See State approved plan Feet ❑Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank seelState approved plan ❑ ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ I ❑ 1 ❑ ❑ 1 ❑ ❑ <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): Plumb is Signatur :(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 715 349-5533 <br /> Plumber's Address(Street,City,State,Zip Cod d): Name of Designer: <br /> Box W Siren, WI 54872 Donald Daniels <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan E. Daniels 3431 <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 Issuin gent Signature jNo Stamps) <br /> pproved ❑ Owner Given Initial Q�^� ( G� 5 � <br /> Adverse Determination � Surcharge Fee <br /> J V"` —+' - _ <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 />