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n Buildings Division <br /> i:•1 �R SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 -^� <br /> than 8 1/2 x 11 inches in size. Burnett ��'C 00 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Num er <br /> 33®3/ _�J <br /> The information you provide may be used by other government agency programs ❑Check it revision to prey ous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I 11-� <br /> Property Owner Name Property Location <br /> Brandon & Rene Winkler NW 1/4 NE 1/4,5 33 T 40 N, R16 l X4r)W <br /> Property275 <br /> Qge1's,lyl�yng,tddress Lot Number 17 Block Number <br /> LL 7 44// IY'11 ..SS n a <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Webster WI 54893 (715 )866-7948 Jessica Addition <br /> II. TYPE TF BUILDING: (check one) ❑ State Owned ❑ Ity Neaarest Road <br /> ❑ Village Oakland G'-ah1es Rd <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms 3 Town OF <br /> III. BUILDING USE: (if buildingtypeispublic,check all thatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1 020 - 9300 - 02 700 <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. a 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 /> 110 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 /> 450 Required (sq.ft.) Proposed(sq.ft.) (GaWday/sq.ft.) (Min./inch) Elevation <br /> 643 648 .7 na 94.00 Feet 97.00 Feet <br /> Capout <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 /> Tanks Tanks <br /> Septic Tank or Holding Tank 1000 1 -- 11000 1 Wieser Concrete ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I ❑ ❑ ❑ ❑ ❑ ❑ <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) Plu er"55 ture' oStamps) MP/MPRSW No.: 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 /> JEDisapproved Sanitary Permit (includesGroundwaler Date Issued Issug Ag tsignature No tamps) <br /> �tCurcharge Fee) F1231Wm <br /> roved ❑Owner Given Initial <br /> dverse Determination �� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 15/94) DISTRIBUTION: Original to County.One copy To: safety B Buildings Division,Owner,Plumber <br />