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DLLHR SANITARY PERMIT APPLICATION <br /> COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> — e Burnett <br /> • _ STATE SANITARY RERMIT#I <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ( 6,kq1 <br /> 8'%x 11 inches in size. ❑ Check If revisi 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. E90-40539 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Daniel W. Gaither GL 3 & 4/a %, S35 T39 , N, R 16 194W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1797 Lincoln 1 ,2,3 na <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OP CSM NUMBER <br /> St. Paul , MN 55105 612 224-452 CSM 1925 �/. )Q oZS� <br /> If. TYPE OF BUILDING: (Check one) 01TM Meenon NEAREST 70 AD <br /> El Owned VILLAGE� y <br /> [:] Public ®1 or 2 Fam.Dwelling-#of bedrooms 3-- PARCEL TAX NUMBER(S) <br /> 018-3335-03-600 018-3335-03-620 <br /> III. BUILDING USE: (If building type is public,check all that apply) 018-3335-03-610 <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. x❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S.❑ 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. T FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 375 1 375 1 .2 3 99.40 Feet 102.40 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total 'of <br /> Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> - <br /> n <br /> Tanks Tanks <br /> Septic ank or HoldinTankW1 r <br /> Concrete <br /> Lift Pum Tank/Siphon Chamber 750 750 1 Wieser Concrete <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): PI bar's Signature:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels 715 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> PO Box 316 Siren WI 54872 <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (includes Groundwater a e esus Issuing Agent Signature(No Stamps) <br /> q`�L Surcharge Fee) <br /> Approved ❑ Owner Determial l O /D q'_(�7� <br /> AdverseDetermin ion (f ll <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb•67)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />