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Safety Buildings Division <br /> VisconsiSANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> n In accord with ILHR 83.05,Wis.Adm Code P.O.Box 7969 <br /> Depe-tment of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County 7� <br /> than 8 112 x 11 inches in size. Rllrnptt <br /> �3 LP CJ <br /> • See reverse side for instructions for completing this application State San"ittaaryyPPeermitit Number <br /> The information you provide may be used by other government agency programs E]Chat; fevisibh to previo6s application <br /> IPrivacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION 9� <br /> Property Owner Name Property Location <br /> Robert EricksonUj <br /> SE 1/4 NW 1/4,S 19 T40 N, R 17 /fl(bl)W 1s <br /> Property Owner's Mailing Address Lot Number Block Number C7 <br /> 10419 County Rd F na I na <br /> Ci St to Zip Code Phone Number Subdivision Name or CSM Number <br /> an�ury WI 1 54830 (715 ) 656-4440 na <br /> 11. TYPE B ILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> Public 1 or 2 FamilyDwelling-No. of bedrooms *1 D Town of Union County Rd 'IF" <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 1 036-4419-01 400 <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. Q Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> E <br /> ------System--------------System------------------- Tank-----Only---------------Existing System---------------------Existing System <br /> ------------ <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 /> 1 1 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 U 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) Elevation <br /> 450 562 572 .8 na 93.50 Feet 97.00 Feet <br /> Capact <br /> VII. INFORMATION in allons Total #Of Manufacturer's Name Prefab. Site Con- Steel Fiber- Plastic Exper- <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank eser ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 11 ❑ ❑ ❑ ❑ ❑ <br /> Vill. 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) ps) MP/MPRSW No.: Business Phone Number: <br /> Donald DanielsJ,�n= <br /> MP 330 1715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> ❑ ZZ <br /> Approved Owner Given Initial / /�,5urrhar9el` e) /J p <br /> Adverse Determination r ��`t/U <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety d Buildings Division.Owner.Plumber <br />