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01(_ w) j (_r <br /> Safety and Buildings Division <br /> Bureau of Building Water Systems <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave <br /> P.O.Box 7969 - <br /> In accord with ILHR 83 05,Wis.Adm-Code Madison,WI 53707-7969 <br /> r <br /> mach complete plans(to the county copy only)for the system,on paper not less County Burnett GG71+ <br /> than 812 x11 inches in size. State Sanitary Permit Number ^, <br /> • See reverse side for instructions for completing this application agr7I S 1 0 <br /> The information you provide maybe used by other government agency programs ❑check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)L State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF ORMATpION596-21188 <br /> Location N, R 18 ��S/ W <br /> Pr,Q pertyownerN me 1/4 114,5 20 T37 <br /> Ject-- 1031 Services Inc Block Number Blo <br /> Lot Number <br /> Property Owner's Mailing Address 5 na <br /> 40 Lake Bellevue Suite 101 <br /> Zip,CAd� Phone Number Su dLvisiov0fm opC0SM1�t)Lnber <br /> Cizy�Sltfevue WA 7t5UU ( ) 11 MM bl1 Nearest Road <br /> tt33 1 State Owned D city <br /> 11. TYPE OF BUILDING: (check one) ❑ ❑ village Trade Lake Erickson Lane <br /> Public © 1 or 2 Fa,mily Dwelling- No.of bedrooms 2_ __ n Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> Parcel Tax Number(s) <br /> 034 - 1520 - 04 100 <br /> 1 ❑ Apartment/Condo Outdoor Recreational Facility <br /> 2 F1 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ <br /> 7 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 3 ❑ Campground ❑ erc12 [-1ServiceStation/Car Wash <br /> 4 [:] Church/School 8 ❑ Mobile Home Park <br /> office/Factory 13 ❑ Other: specify <br /> 5 ❑ Hotel/Motel 9 ❑ <br /> EA) <br /> TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) Repair of an <br /> New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ p . <br /> Tank only Existing System _ Existing System <br /> 1 --System ❑ System --------------------y-------------- <br /> ----- -"-------""-"-- Date issued <br /> ) ❑ A Sanitary Permit was previously issued. PermitNumber <br /> . TYPE OF SYSTEM: (Check only one) Other <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Holding Tank <br /> 11 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 U g <br /> 22 In-Ground Pressure 42❑Pit Privy <br /> 12❑Seepage Trench ❑ 43❑Vault Privy <br /> 13[:]Seepage Pit <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. Pert. Rate 6. System Elev. Elev7. ation <br /> RequiredRequired (sq- ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) na Feet <br /> 300 na na na na n a Feet <br /> VII. TANK Capacity TOtal #Of Prefab. Site Fiber- Plastic Exper. <br /> INFORMATION gallons Gallons Tanks Manufacturer s Name Concrete con- steel glass APP <br /> New Existin strutted <br /> Tanks Tanksn n <br /> Septic Tank or Holding Tank 2000 -- 2000 1 Wieser COnCretP. El O M n ❑ ❑ <br /> LlftPumpTank Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> IP� EPAR <br /> the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> e:(Print) <br /> ber"s S tore:(N Stamps) MP/MPRSW No : Business Phone Number: <br /> aniels MP 330 715-349-5533 <br /> ress(Street,City,State,Zip Code): <br /> 16 Siren WI 54872 <br /> TY/ DEPARTMENT USE ONLY <br /> Sanitary Permit Fee (IndudesGroundwater atelszue Iss - g gent Signa ure(NoStamps) <br /> ❑Disapproved iT�naryd ❑Owner Given InitialAdverse Determinationi. <br /> ITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SNIt-ti 398(rf.OS194) D6iBIBUTInp_-^�ginal to Counl y,One copy To: Sefety b BuilJi nyy Oim:ion,Owner,PlwnrKr <br />