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Safety and Buildings Division <br /> Vti�rin SANITARY PERMIT APPLICATION Bureau of Building Water System-. <br /> Ina ccord with ILH201 E.Washington Ave- <br /> R 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 112 x 11 inches in size. Burnett <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑Gheck if 30 n to pre ious application i <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name PropertyLocation <br /> Robert & Janice Mettler SW 1/4 SW 1/4,S 4 T40 N, R16 /V(or)W <br /> Property Owner's MarlinAddress Lot Number Block Number <br /> 7384 Hayden La�Ce Rd 1 na <br /> Cit State <br /> ta u r WI Zip,{ocj o Phone Number Subdivision Name or CSM Number <br /> y jV (715 ) 656-3193 CSM Vol 15 Pg 191 <br /> 11. 1 YPE UF BUILDING: (check one) ❑ State OwnedD City Ne�rest R{(oad <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms 11 E3Tow9 of Oakland f1 a. en Lake Rd/S� r <br /> Ki III. BUILDING USE: (If buildingtype is public check allthatapply) Parcel Tax Number(s) <br /> 020 -4304 - 01 800 <br /> 1 ❑ Apartment/Condo <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 box on line A. Check box on line B, if applicable) <br /> A) 1. ❑ New 2- ® Replacement 3. ❑ Replacement of 4, ❑ Reconnection of 5_ ❑ Repair of an <br /> __ System _System _____ _ Tank Only ______ Existing S <br /> ____ gstem_yExisting System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 M Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per7600 <br /> 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 /> 857 X51 882 .7 na 93.00 Feet 96.00 Feet <br /> VII. TANK Capacity <br /> in gallons Total #ofPrefab. Site Fiber- Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1200 -- 1200 1 Wieser Concrete ® ❑ ❑ ❑ ❑ ❑ <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) A&=�Y` <br /> T P/MPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> PO Box 316 Siren WI 54872 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater F—/9-1?21 <br /> te IssuedIssuing ent Signature(No Stamps) <br /> Approved Surcharge Fee) �y-�pp ❑Owner Given Initial I�-QO / f [Gifu <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />