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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code 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 8 112 x 11 inches in size. Burnett <br /> 9 See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3)86ao <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> ]Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 77274 <br /> Property Owner Name Property Location <br /> Robert Todd GL5 1/4 114.523 T40 N, R 17 "POW <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 14 na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> St Croix Falls WI 54024 V15 ) 483-3241 CSM Vol 1 Pq 112 <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ village Union Grover Pt Rd <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 2 Town OF <br /> III. BUILDING USE: (If building type is public,checkallthatapply) Parcel TaxNumber(s) <br /> 036-4423-05 100 <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 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 /> 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev- 7. Final Grade <br /> 300 Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 1- Gallons P 757 <br /> 429 429 .7 na 101 .05 Feet 103.3OFeet <br /> C <br /> VI1. apacltNFORMATION in gallons Total #of Prefab. Site Fiber- Exper. <br /> g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ 1 ❑ 1 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 600 -- 600 1 Wieser comb ® ❑ ❑ I ❑ 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) Plu er's Si n ure No Sta s) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels �� � MP 330 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee <br /> A pp roved ❑ (lnrdulde6rouen)dwater te/sIsfue <br /> Issuing <br /> �A ntSignature(No Stamps)ignature(NoStamps) <br /> Owner Givenal surchargere <br /> Adverse Determination <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 58D-63981R_05/941 DISTRIBUTION: Original to County.One copy To: Safety 8 Ruildings Division,Owner,Plumber <br />