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SANITARY PERMIT APPLICATION COUNTY <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> �� s• �� STATE ANITA PERMIT#' 1 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 06!5)8 <br /> 8'%x 11 inches in size. ❑ Check If revs 2n 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. S92-20669 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Rudolph Melin SW % SW %,S 32 T37 N, R 18 /Wy W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 2927 h na n a <br /> CITY,STAT urg WI Z154840 PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> I. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> I <br /> ❑ state owned VILLAGE: Trade Lake 230th <br /> ❑ Public ❑x for 2 Fam. Dwelling-#of bedrooms 3— PA O xNu R( ) 620 <br /> Ill. BUILDING USE: (If building type is public,check all that apply) v -53 — 0 a <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/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 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 ❑ 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 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 /> 450 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allOns Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name c ncrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holdina Tank 2000 1 12000 t 1 Sk <br /> Lift Pump Tank/Siphon Chamber <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): Plumber's Signature:(No mps) MP/MPRSW No.: ]r(u7 <br /> siness Phone Number: <br /> Donald Daniels15 349-5533 <br /> Plumber's AddressStreet,City,State,Zip Code): <br /> PO Box 319 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e711ssue I I <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial - � <br /> Adverse Determination (35. ^w <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />