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"" Safety and Buildings Division <br /> vCi 11� SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E.Washington Ave. <br /> In accord with ILHR 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 �� r I <br /> than 8 12 x 11 inches in size. Burnett o <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numberr� <br /> The information you provide may be used by other government agency programs E]Check if evis3 t�vfo�apipllcation <br /> ]Privacy Law,s. 15.04(1)(m)]. State Plan I.D. umber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Ip <br /> Pr It Own r N me Property Location <br /> �gIYfer Kn'Iren NE 1/4 NE 1/4,S20 T 39 N, R 1WAor)W <br /> Pro rtyOwWy Mailing Lot Number Block Number <br /> 947 H5W2 na <br /> City,State N Zip Code Phone Number Subdivision Name or CSM Number <br /> Webster WIC 1 54893 1( 715) CSM Vol 11 pg 19 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms ° Town or Meenon Hwy 35 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 018 - 3320 - 01 810 <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 Existing System <br /> ----------------------------------------------------------------------------------------------- <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 Pe77a7l 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 /> 600 857 857 .7 na 9 Feet Feet <br /> Capacit <br /> VII FORMATION in allons Total #of Manufacturer's Name Prefab. Con_ Steel Fiber- Exper <br /> Gallons Tanks concrete glass Plastic App <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1250 1 11250 1 Wieser Concrete ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 750 -- 750 1 Wieser Concrete ❑ ❑ ❑ ❑ ❑ <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) amps) MP/M <br /> mw= <br /> PRSWNo.: 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 ate Issue Issuing Age t Si nature(No Staimpl <br /> roved ❑Owner Given Initial 6c)su,chargeteel 9 Cj <br /> Adverse Determination ��lg�' / oZ ` <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original G)County,One copy To: Safety 8 Ruilclm%Division,Owner,Plumber <br />