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Safety and Buildings Division <br /> %S`>CODSID SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code P BOX 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. Burnett v1-77 <br /> c�� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for seconds purposes y p y secondary p rP ❑Check if revisio to previous application <br /> [Privacy Law,s. 15.04(1)(m)1. State Plan I.D. tuber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION 7--�8 <br /> Property Owner Name Property Lcation <br /> Tami Viernow GOVALOt 9 1/4,S 36 T 40 N, R15 lVtor)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3319 26th Ave na na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> lap 61201 <br /> ( ) 788 1669 VM VnI 3 Pn 156 <br /> II. <br /> MPHIF B ILDING: (check one) ❑ State Owned 0 uty Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms �_ °Towan of Jackson Mallard Lk Rd <br /> III. BUILDING USE: (if buildingtypeispublic,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 012 - 4236 - 06 800 <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 online B,if applicable) <br /> A) 1. ❑ New 2. a Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System --------System ___ - Tank Only--------------- <br /> --- --- ExistingSystem ExistingSystem <br /> B) El 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 �Cj 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. 1 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) I T Elevation <br /> 450 na na na na Feet Feet <br /> act <br /> VII. TANK in Ca gallons Total #of Prefab. Site Fiber- Plastic Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 2noo __ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ El <br /> Vill. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibi ity for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) P er' -gnat -(ryo tamps) 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 /> ❑Disapproved Sanitary Permit Fee (Includ sGround"ter ate issued Issuing Age t5 nature roved F1❑Owner Given Initial / z� (jefee) <br /> 77 Adverse Determination ! <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SBD-6398 IRA 1/97) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,Plumber <br />