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APPLICATION FOR SANITARY PERMIT <br /> (�)iD I L H R Burnett COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT # <br /> nEPRRTT,LR OF <br /> ^IX15TRV,LRbOR 6MUfnPn RELRT1On5 <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Code for the system, on paper not less than 87:x 11 incheessJ'ii in/lsize, /\ <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Bob Albrecht Rt. 3 Box 197A Frederic, WI 54837 <br /> PROPERTY LOCATION CITY: <br /> GL 51/4 1/4, S 5 , T38, N, R 1l W owN oF: LaFollette <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> na <br /> TYPE OF BUILDING OR USE SERVED <br /> 11 1 or 2 Family Number of Bedrooms. 2 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System 9 Tank Replacement ❑ Repair <br /> iJ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy <br /> ❑ Existing, For Which A Previous Permit Is On File, Permit # issued <br /> ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. <br /> Total #of Prefab, Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity 750 1 x <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: TMC Inc. <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATEABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> 3 410 420 6�-] Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print): Signat / � MP/MPRSW No.: Phone Number: <br /> Donald Daniels YL1�!- il1/.�-�"� MP 330 (715 463 2333 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren, WI 54872 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign ure of Issuing Agent: Fee: Date: ❑ Disapproved <br /> / ElOwner Given Initial <br /> q:5, G-a Y Approved Adverse Determination <br /> P�Ion for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DILH R-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />