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—safety and Buil rags DI. <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> ons►n In accord with ILHR 83.05,Wis.Adm.Code P.O.Box <br /> Madison,Wl WI 53707.7969 <br /> of Commerce <br /> tAuacn Complete plans(to the County copy only)for the system,on paper not less county Ill <br /> than 8 1/2 x 11 inches in size. Burdett ;;I3g3s <br /> • See reverse side for instructions for completing this application State SanitaryPermit <br /> The information you provide may be used by other government agency programs ❑Check it revlslonTo previous application <br /> IPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION 183622 <br /> Property Owner Name Property Location <br /> Tim T'ader E1/2NE1/4 NW 1/4,S 14 T38 N, R 17 E(o )W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 23976 Tollandpr Rd na na <br /> Cit ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Ski ren WI 1 54872 1(715 ) 349-5192 na <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ itllage DanielDaniels 70 Nearest Road <br /> S <br /> D <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 ❑ viTown OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 006 - 2414 - 01 800 <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. M Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> system --------System _____________ Tank Only _--________ ExlstingSystem ___ _ 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 Q Mound 30❑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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft_) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 450 1100 1128 .4 na 1 100.6 Feet 103.6 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Aper <br /> INFORMATION Gallons Tanks Concrete glass App. <br /> New Existing <br /> strutted <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank 1000 -- 1000 1 Wieser Concrete IQ ❑ ❑ ❑ ❑ ❑ <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) Plu tier's at :(N Stamps) MP/MPRSW No : Business Phone Number: <br /> Donald Daniels MP 330/221593 715-349-5533 <br /> Plumber's Ac dress(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 ate ssue Issuing A# <br /> nt Signature(No Stamps) <br /> roved surcharge Fee) <br /> pp ❑Owner Given Initial �, O��„� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD•6396(R.11/96) DISTRIBUTION: Original to County,One copy To:Safety&Buildings Division,Owner,Plumber <br />