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SAN ITA RY PERMIT APPLICATION Safety and Buildings Division <br /> AsoiI;onsin <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less county� � ` <br /> than 8 12 x 11 inches in size_ [3wi.)ao o (� <br /> 0 See reverse side for instructions for completing this application State Sanitary Pers ryt, ber <br /> The information you provide may be used by other government agency programs ❑Check if revision t�o pr/evious application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> 1- APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name 1_ Property t,ocation <br /> :04-, 045&A.4 sit i4# 1/4,S JLe T 4/0 ,N, R /� W <br /> Property Owner's Mailing Address Lot Nu ber Block Number <br /> em" Mv1nL. )- a <br /> City,State Zip Code- Phone Number Subdivision Name or CSM Number <br /> or Lc): ,5.)(S o (7i5)3 9SB <br /> II. LDING: (check one) ❑ State Owned ❑ ityge Nearest Road <br /> El r� <br /> Public 1 or 2 FamilyDwellingC] Villa- No.of bedrooms � own of �toff <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) �Q„ 14i�1-__ O�_-7FFrl <br /> 1 ❑ Apartment/Condo 777/0 A1rL&-' ZAtp <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. PKNew 2. ❑ 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 Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 E]Mound 30❑Specify Type 41 E]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 Per Day 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) rj / Elevation <br /> So 3 /? . 7 "70'.144Feet qf!/ Feet <br /> Capacot <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. Site Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete structed glass App <br /> Tanks Tanks <br /> Septic Tank orH /Op0 9 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank p ❑ ❑ ❑ ❑ ❑ <br /> Vill. RESPONSIBILITY STATEMENT <br /> 1,the undersign me responsib' ity for installati4 of the onsite sewage system shown on the attached plans- <br /> Plumber's <br /> lans_ <br /> Plumber's�,J,Pf}tlt)& EXCAVATIO I m s5 nature: Stamps) PRSW No.: Business Phone Number: <br /> ��CC1hN11iiN622 as y <br /> Plumber's Addresri Mp Code): <br /> (715)835-7482 <br /> IX. COUNTY/DEPARTMENT USE ONLY — <br /> ❑Disapprove d Sanitary Permit Fee (Includes Groundwater s �rlg n ature(NoStamps) <br /> Approved surcharge Fee) u <br /> pp ❑Owner Given Initial I�. <br /> Adverse Determination CKD kin <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: j APR3 0 1995 <br /> 1 <br /> BURNETT COUNTY <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: safety 6 Buildings Division,Owner,plumber <br />