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Li o�LHr� SANITARY PERMIT APPLICATION COUNTY BURNETT <br /> _ In accord with ILHR 83.05,Wis.Adm.Code <br /> ���• � STATESANITARY ERMIT#13,Zp / <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than I <br /> 8'%x 11 inches in size. El Check if ievSsYo o previous application <br /> –See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> RAY PETERSEN NE '/4 SW +/4, S 22 T39 , N, R 14 ��pf)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 8755 S. KELLER AVE. NA NA <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> HOMETOWN, IL 60456 <br /> 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑State Owned VILLAGE:RUSK PINE ROAD <br /> ❑ Public ®1 or 2 Fam. Dwelling,#of bedrooms 2 PA EL TAX UMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) a�1_– as—0- <br /> �i <br /> 1 ❑ Apt/Condo Y �A <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ 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. ® New 2. 0 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ 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 LJ Seepage Bed 21 ❑'Mound 30 ❑ Specify Type 41 Holding Tank <br /> 12 El Seepage Trench 22 ❑*In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> V1. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PERDAY 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 /> 300 410 410 .73 <3 93.7 Feet 95. 7 Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New is <br /> Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:IN mps) MP/MPRSW No.: Business Phone Number: <br /> MELVIN J. FERGUSON � 3393 715 635-7595 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> P.O.BOX 71 , SPOONER, WI 54801 <br /> IX.,COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved SanitaryPermit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial Q '�� 1 c–,rYlrV <br /> Adverse Drmin tion I <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 />