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SANITARY PERMIT APPLICATION UIN 0 <br /> �iZrin <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY lq& <br /> Burnett <br /> STATE SANITARY-PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 81/2 x 11 inches in size. ❑ Check if revision 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. moi' <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Michael & Judi Vasatka Elk yt SE y4 S 20 T 38 , N, R 15 t/(6r)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 23361 County Rd "B" PO Box 41 na na <br /> CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> firen WI 51 2 715 349-7478 na <br /> il. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned o TILLAGTOWNE: LaFollette County Rd "B" <br /> ❑ Public ©1 or 2 Fam. Dwelling-#of bedrooms 3— PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 014 - 2220 - 02 300 <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 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 ❑ Specity Type 41 ❑ Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 El'Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQytR1Eb(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 643 <br /> nA 93Feet q Feet <br /> CAPACI X" <br /> VII. TANK Site <br /> ns Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks I Tanks structed <br /> Septic Tank or Holding Tank 10001 11000 1 Wieser Concrete <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu is Signature' N mps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels 1 <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(Includes Groundwater a e s ue Issuing Signat e( pa) <br /> SurchApproved ElOwner Given Initial 1 5,6 / <br /> Adverse Determination / CJ [ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> SBQ6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />