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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATIONS <br /> Visconsin 201 W.Washington Avenue <br /> n accord with ILHR 83.05,Wis.Adm.Code P O 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 8112 x 11 inches in size. Burnett aa�� <br /> • See reverse side for instructions for completing this application State Sanitary Number <br /> F9 W <br /> Personal information you provide may be used for secondary purposes ❑Check if vision to pp_'reviLouuuss application / <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number Lr <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION IlL� <br /> Property Owner Name Property Location <br /> Jack French NE 1/4 NE 114,S 14 T 37 ,N, R 18 ,E1XJ6Y)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 454 Locust na na <br /> City State Ott WI Zip C cle Phone)umber Subdivision Name or CSM NumberPrest\ l <br /> 262-3467 na <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village <br /> Public 0 1or2Family Dwelling- No.ofbedrooms 3 W Town OF Trade Lake Whisperinq Pines Rd <br /> III. BUILDING USE: (If building type is public,check all that apply) Farcel Tax Number(s) <br /> 034 - 1514 - 01 100 <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. ® New 2. ❑ 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 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 3C ❑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 /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 6./0 Elevatiorgo.30 <br /> 450 562 572 .8 na Feet 98. Feet <br /> Ca act <br /> VII. INFORMATION in allo s Total #of Prefab. Site Fiber- Exper <br /> g Gallons Tanks Manufacturer's Name Concrete con- steel glass Plastic App <br /> New Existingstrutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 600 -- 600 1 Wieser comb. � ❑ ❑ ❑ ❑ ❑ <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) No Sta ps) MP/MPRSW No.: Business Phone Number: <br /> Axt <br /> ure <br /> Donald Daniels715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> PO Rnx '116 .1;i rPn WT S4272 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate IssuedIssuing g t Signa re(No to ps) <br /> roved �Surcharge Fee) <br /> pp ❑Owner GivenInitial I �� <br /> Adverse Determination / f I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />