Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY <br /> D'■ 1. R Burnett <br /> `■■ 7YpIn accord with ILHR 83.05,Wis.Adm. Code STATE SANITARY PERMIT# <br /> 5 i3oa8 <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8'/2 x 11 inches in size. 8702650 <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 /> Richard Engstrom GL3 '�4 /4, S 2 5 T39 . N, R 16 xF>{ P) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> Siren, WI 54872 <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> Siren WI 1 5487;) 715-) 4 - 88 E VILLAGE : Meenon Pike Lake <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. © 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. Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.L1 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 /> 3 250 252 moundFeet x❑Private El joint El 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 A <br /> Tanks Tanks structed pp <br /> Septic Tank or HoldingTank __ El <br /> Lift Pum Tank/Si hon Chamber 0 -- "comb. tank It ❑ ❑ ❑ ❑ <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's Signature:(No Stamp MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 715 349-5364 <br /> Plumber's Address(Street,City,State,Zip C de): Name of Designer: <br /> Box W Siren, WI 54872 same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> FAWArd Sohrriptipr nil 91 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved S1anniitary Permit Fee Groundwater ate Issuing A ant Signature(No Stamps) <br /> Approved El Owner Given Initial ,�N ''l�`h/l Su charge Fee q—s A <br /> Adverse Determination �rOr N) as Jr—�y g <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> t <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />