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60 <br /> U I Safety and Buildings Division <br /> SANITARY PE 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 ans o the county copy only)for the system,on paper not less County <br /> trlan 8 112 x 11 inches in size. Burnett <br /> rw <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 340 6107 <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I S97 - 20810 <br /> Property Owner Name Property Location <br /> NW 1/4 SW 1/4,S 35 T 39 N, R 16 /V(W)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 426 State Rd 46 na I na <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> AMerX W4 1 54001 1( 71qj26,q-771,Q nA <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village Meenon Hiway 70 <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms Z Town of <br /> III. BUILDING USE: (If buildingtypeispublic,checkallthatapply) Parcel TaxNumber(s) <br /> 18 - 3335 - 03 700 <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. Q Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System ___ _______ Tank-Only-- Existing System _ ___Existing System <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 /> 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.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 1.Gallons P 737375 375 7 n Feet Feet <br /> Capact <br /> VII. TANK in allons Tota[ #of Prefab. Site Fiber- plastic Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1000 -- 1000 1 Wieser Concrete 12-1 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/SiphonChamber 600 -- 600 1 Wieser comb. 0 ❑ ❑ ❑ ❑ ❑ <br /> Vill. 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 rs Si n ure: Stamps) 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 /> E]Disapproved Sanitary Permit Fe pndudes Groundwater ate slue Issuing Agent Signatu a(N S mps) <br /> Surcharge fee) /� <br /> proved F1 Owner Given Initial [f/// ./ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: J <br /> 71774 <br /> SOD-6398(R.05/94) DISTRIBUTION: Original to Counly,One copy To: Safety 8 RuiWings Division,Owner,Plumber <br />