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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> Visconsin In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8112 x 11 inches in size. Burnett <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nu bl/er <br /> The information you provide may be used by other government agency programs ❑Check it,evision to previou application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION I _ <br /> Pro rty Owner Name Property Location <br /> Ceassell Hauser 1/4 1/4,S T 40 N, R 15 M000 W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 7063 17th ST N 29 & 30 na <br /> City,State Zip Code P e N er Subdivision Name or CSM Number <br /> St Paul - ) ki-2306 Deer Lodge addn to Voyager Village <br /> II. TY F B ILDIN : (check one) ❑ State Owned !ty Nearest Road <br /> ❑ Vdage Jackson Deer Lodge Trailuay <br /> Public 1 or 2 Family Dwelling-No.of bedrooms Eg Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 012-9225-03 900 & 01.2 — 9225-04 <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. Iq New 2. ❑ Replacement 3. [] Replacementof 4: ❑ Reconnection of 5. E] Repair of an <br /> System System ____-------------I Tank Only---------------Existing System ___ ____ExistingSystem <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE DF 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 /> 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.) (Gals/day/sq.ft.) (Minlinch) Elevation <br /> 563 572 .8 na 95.00 Feet 98.00 Feet <br /> TANK Ca act Site <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App <br /> New <br /> Tanks <br /> Septic Tank or Holding Tank 0 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vlll. 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 mber'sSign tura (NoSta s) MP/MPRSW Business PhoneNumber: <br /> Donald Daniels LL NIP 330 �593 715-349-5533 <br /> Plumber's At dress(Street,City,State,Zip Code): <br /> PO Box 316 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanit Permit Fee (Includes Groundwater ate ssue Issui A ntSi ature oStamps) <br /> �Arpproved Owner Given Initial Surcharge fee) <br /> ✓V ❑Adverse Determination 7,"cab <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.l IM6) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />