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N Gnolf, <br /> Safety an <br /> SANITARY PERMIT APPLICATION Bureau of BulildinggWaterlon System, <br /> In accord with ILHR 83.05,Wis.Adm Code 201 E.Washington Ave <br /> P.O.Box 7969 <br /> ' Madison,WI 53707-7969 <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 e2oo?,9p <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number•//� D <br /> The information you provide maybe used by other government agency programs 9 8 9 l /, <br /> [Privacy Law,s. 15.04(1)(m)]. E]Check it revision to previous application <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION State Plan I.D.Number <br /> Property Owner Name <br /> Lydell Larson Property Location <br /> SW 1/4 SE 1/4,S 11 T 37 N, R 18 r)w <br /> Property Owner's Mailing Address Lot Number <br /> 1693 335th Ave Block Number <br /> City,Srederi c �,f I ZIP ode Phone Number Subdivision Name or CSM Number <br /> 5437 ( 715) 327-8572 na <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 Family Dwelling-No.of bedrooms 5 ❑ village Trade Lake <br /> -- -- Town OF Spirit Lk Rd <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 034 - 1511 - 04 800 <br /> 2 ❑ Assembly Hall 6 ❑ Medica] Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 p Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park <br /> 5 El Hotel/Motel 12 E] Service Station/Car Wash <br /> 9 El 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 <br /> System 2. ❑ Replacement 3. ❑ Replacement of q ❑ Reconnection of S Repair of an <br /> -___-_ y_ Tank Only -- - - - Existing System ❑ ExistingSystem <br /> - -------------- --------------------- -------------- -y---- <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 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure <br /> 13[-]Seepage Pit 42[1 Pit Privy <br /> 14❑System-In-Fill 43❑Vault Privy <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 /> 750 Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 1071 1 1 na 96.30 Feet 99.30 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab. Site Fiber- Exper <br /> New Existin Gallons Tanks Manufacturer's Name Concrete st noted Steel glass Plastic App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1565 -- 1565 1 Wieser Concriatia ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I ❑ ❑ ❑ ❑ ❑ ❑ <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) PI ber's S n tar (No Sta ps) MP/MPF SW No-: Business Phone Number: <br /> Donald Daniels MP 330 <br /> Plumber's Address(Street,City,State,Zip Code): 71 -349-5533 <br /> PO Box 316 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved SanitaryermitFee lindudesGroundwater ate}ssue <br /> urcnargefee) / issuing Age Signature osglps) <br /> pproved E]Owner Given Initial �6� �'� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FO DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to Couniy.One copy To: Safety&Buildings Dimsion,Owner,Plumber <br />