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safet <br /> ildis <br /> �'ic� rTi SANITARY PERMIT APPLICATION BureauaofBulilding Water'Systems <br /> In accord with ILHR 83 05,Wis.Adm.Code 201 E Washington Ave. <br /> P.O.Box 7969 <br /> 0 Attach complete plans(to the county copy only)for the system,on paper not less W9 , <br /> Madison,WI 53707-7969 <br /> than 8 1/2 x 11 inches in size. <br /> 0 See reverse side for instructions for completing this application rrurnet Per Numb oThe information you provide maybe used by other government agency programs `� ��[Privacy Law,s. 15.04(1)(m)]. ision to previous application <br /> I. APPLI ATION INFORMATION - PLEASE PRINT ALL INFORMATION _NumberProperty Owner Name <br /> 20374Yvonne Merchant Property LocationProperty Owner's Mailing Address GL3 t/4 v4, 39 N, R16 E/(¢6 N/ ll <br /> La nteur Ave E #D Lot NumberBlock Number <br /> f2l <br /> tateZip Code Phone Number Subdivisio�N�ne orCSM Number na <br /> t Paul MN 55117 ( 612) 771-7508 CSM V 2 Pg 57 <br /> 11. TYPE F BUILDING: (check one) �OU , � 3 <br /> ❑ State Owned ❑ city Nearest Road <br /> Public 1 or 2 Famil Dwellin - No. of bedrooms ❑ village Meenon <br /> Z— Town OF JohnStone Rd <br /> 111. BUILDING USE: (If building type is public,check all that apply) arcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 018 - 3303 - 04 300/200 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursingme <br /> 3 ❑ Campground 7 Ho10 ❑ Outdoor Recreational Facility <br /> ElMerchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park <br /> 5 E] Hotel/Motel 12 E] Service Station/Car Wash <br /> 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> New <br /> A) 1 ❑ <br /> System -- -2 ® Replacement 3 ❑ TaPk Onment of q. ❑ Reconnection of 5. ❑ Repair of an <br /> ---- __ y____ Existing System----------------- -------g-y------------ Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Y <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution <br /> Experimental Other <br /> 11 ❑Seepage Bed 21 ®Mound <br /> 12❑Seepage Trench 30 El Specify Type 41 ❑Holding Tank <br /> 22❑In-Ground Pressure 42 E]Pit Privy <br /> 13 E]Seepage Pit <br /> 14❑System-In-Fill 43❑Vault Privy <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6_ System Elev. 7. Final Grade <br /> 300 Required(sq. ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Min./inch <br /> 429 429 ) Elevation <br /> VII. TANK Capacity <br /> •7 na 108.08 Feet 111 .8 Feet <br /> INFORMATION in gallons Total #of site <br /> Gallons Tanks Manufacturer's Name Prefab. <br /> New Existin Concrete Con- Steel Fiber-ass Plastic EAxPpr. <br /> Tanks Tanks strutted <br /> SepticTank orHolding Tank 1000 -- 1000 1 Wieser Concrete El <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plu er's g to :(No St m s <br /> Donald Daniels p ) MP/MPRSWNo: B=715-349-5E533 <br /> Plumber's Address(street,city,state,Zip code): MP 330 <br /> PO Box 316 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ;Ii ❑Disapproved Sanitary Permit Fe (includesGroundwaler pte sue Iss ing Agen ign ure(N S m s <br /> Approved ❑Owner Given Initial oZ �d s°`` a'g`ree) 6 p ) <br /> v Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05194) DISTRIBUTION: Original to CauMy,pee ropy To: Sorely&Buildings Division,owner,plumber <br />