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I-- MEMM <br /> SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code Burnett <br /> �~ STATE NITA ERMIT#/�OOS9 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ���3 <br /> 8'/z x 11 inches in size. ❑ Check If reviai to previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. O C� <br /> PROPERTY OWNER PROP"/4 <br /> ON <br /> Gerald Hayes ,S 27 T38 N, R 18 <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 11513 N Shore Dr 6 1 na <br /> CITY,STATEZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Grantsburg WI 54840 715 689-2841 North Share Island View <br /> 11. TYPE OF BUILDING: (Check one) El <br /> CITY : NEAREST ROAD <br /> State owned VILLAGE: Wood River N Shore Dr <br /> ❑ Public ©1 or 2 Fam. Dwelling—{hof bedrooL TAX NUMBER(S) <br /> 111. BUILDING USE: (If building type is public,check all that apply) <br /> 9/ dS - OI 67 PO <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/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 in line A. Check 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 /> B) ❑x A Sanitary Permit was previously issued. Permit#V C�0 a q Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑ Seepage Bed 21 F9 Mound 30 EJ Specify Type 41 El Holding Tank <br /> 12 ❑ Seepage Trench 22 In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 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 /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in aallons Total #of Pref ab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks I Tanks strutted <br /> Septic Tank or Hotdina Tank <br /> Lift Pump Tank/Siphon Chamber 1 750 750 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): PI bar's Sign re: o Stamps) MPIMPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 715 349-5533 <br /> Plumber's Address(Street,City,Stale,Zip Code): <br /> PO Box 316 Siren WI 54872 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater a ssue Is Ing gent Si ure(No Stamps) <br /> Approved ❑ `�! <br /> Owner Given Initial ,' ,surcharge Fee) -/0-49, <br /> Adverse Determination <br /> l�'lJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />