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17- mm" SANITARY PERMIT APPLICATION COUNTY <br /> OILHRIn accord with ILHR 83.05,Wis.Adm.Code Burnett `, <br /> �• �� STATE SAN PER PER T#083 <br /> I <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than l l 7q&;, <br /> 8'%X 11 Inches In size. ❑ Check if revision to evious application <br /> -See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. GL S89-20442 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Forts Folle AVoine/Burnett Cty. Hist. Soc. SE % NW %, S24 T40 , N, R 17 /H4dr) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# /'� BLOCK# <br /> PO Box 31 100 Johnson St. ma rs� L 1 na <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Siren, WI 54872 715 349-221 na <br /> 11. TYPE OF BUILDING: (Check one) ❑ State Owned LJ CITY VILLAGE: Union NEAREST ROAD <br /> County "U" <br /> Public ❑1 or 2 Fam. Dwell ing,#of bedrooms— R L22A/X NUMBEKI )) 41 <br /> 111. BUILDING USE: (If building type is public,check all that apply) 0✓� T Y�7 �'z" — C)6) <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 ® Restaurant/�"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) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑ Seepage Bed 21 ❑x Mound 30 ❑ Specify Type 41 ❑ 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 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 600 500 500 .8 4 96.85 Feet 98.85Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- p <br /> Manufacturer's Name . <br /> INFORMATION New Existing Gallons Tanks Concrete Con- Steel glass Plastic App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank <br /> Lift Pum TanWSi hon Chamber 790 -- <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): Plu is Signature:(No mps) MP/MPRSW No.: T(775 <br /> es Phone Number: <br /> Donald Daniels MP 330 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> PO Box 316 Siren, WI 54872 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Santlary Permit Fee(Includes Groundwater a e"nue — <br /> Disapprovednt Signatu Stamps) <br /> �, I1c)�urckerge Fee)Approved ❑ Owner Given Initial yJ 1!✓\DJ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />