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� Safety and Buildion <br /> �.Isconsin SANITARY PERMIT APPLICATION 2 1 W.Box Washington Avenue <br /> 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <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 /> _3( �?6 <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. tate PIn I D. er <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INE ORMATI N rans 327sTT Site # 195491 <br /> Property Owner Name PropertY�L.�oc,ation <br /> Donald Young1/4 �° 1/4,S 21 T37 N,R 18 /t/(br)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 12055 Little Trade Dr na I na <br /> City,State Zip Code Phone Number Subdivisioname or CSM Number <br /> Grantsburcf WI 1 54840 (715 ) 488-25. CJ- 3 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Lit� Nearest Road <br /> ❑ vll age Trade Lake Little Trade Rd <br /> Public 5a 1 or 2 Family Dwelling-No.of bedrooms -_ N Town of <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 034 – 1521 – 05 500 <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 System __-----__ExistingSystem <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 ❑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 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) Elevation <br /> 300 na na na holding 1 Feet <br /> Capacrt <br /> VII. INFORMATION in allons Total #of Manufacturer's Name prefab. Con steel Fiber- plastic Exper- <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank 2000 4000 --"Wieser Concre e Q I ❑ ❑ I ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ 1 ❑ ❑ 1 ❑ ❑ ❑ <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) I PI ber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Donald d Daniels 330/221593 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 Sani ei*EludesGroundwater at2 SSUe Issuing Ag t�gnatur No p <br /> roved charge Fee) <br /> p ❑Owner Given Initial <br /> Adverse Determination b 7 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,plumber <br />