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SANITARY PERMIT APPLICATION <br /> aDICOUNTYLHR In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> STATE SANITARY RMIT#a4)8 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 07aa3 <br /> 8+%x 11 inches in size. ❑ Check If revislo 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> James Skog W114SWy4 SE %,S 34 T 39 , N, R 16 tl(br W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 6783 lakeview Rd 1 & 2 "A 2 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Siren WI 1 54872 715 349-5746 -- 2nd Addition to Mound Beach <br /> 11. TYPE OF BUILDING: (Check one It. Meenon NEAREST ROAD <br /> State Owned ❑ VILLAGE <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 2 PARCEL TAX NUMBER(S) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 018-9175-01 400 <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 Existin Syst m <br /> B) A Sanitary Permit was previously issued. Permit# �7� 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 PEW7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 300 REQUIRED AREA <br /> ft.) PROPOSED(sq.ft (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 480 720 .4 feI+ 94.00 Feet 96.75 Feet <br /> VII. TANK CAPACITY Site <br /> in ellons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdinc,Tank State d r v X <br /> Litt Pum Tank/Siphon Chamber. 800 -- 800 1 Skald <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): Plu bar's Signet re:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels ;r I MP 330 715 349-5533 <br /> PlumbeFF''�'s Adddre7 street,City,State,Zip Code): Siren W1 54872 <br /> JX.ICOUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit I"(Includes Groundwater ate Issued Issuin gent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial Surcharae Fee) (x� 2 _ <br /> Adverse Determination ��� —�✓ <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 />