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s ..k Safety an Building Division <br /> ��ISC0115%11 SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce In accord with Comm 83.06,Wis.Adm.Code Madison,WI 53707-7302 <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 a�IaO Sj <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number - <br /> �� 7(9c2, _ <br /> Personal information you provide may be used for secondary purposes ❑check if revs to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Trans # 32591.8 site# 195162 <br /> Pro erty Owner Name Property Location <br /> Ion Melzo SE 1/4 NW 1/4,S 3 T 39 N, R 16 AA05f)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> PO�Stt�aBox 344 �d tob na na <br /> Gt�ebster WI 4�9 �7�ehNv866-4783 SubniasionNameorCSMNumber <br /> .WTYPE BUILDING: (check one) ❑ State Owned ❑ !ty Nearest Road <br /> 3 ❑ vll age County Road A <br /> Public 1 or 2 Family Dwelling-No.of bedrooms m Town OF e <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel TaxNumber(sl8 — 3303 — 05 110 <br /> 1 ❑ Apartment/Condo <br /> 00 <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. Q New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System --------System ------------- TankOnly--- 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 /> 1_Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate S.Perc. Rate 6. System Elev. Final Grade <br /> RequiredProposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) El7.evation <br /> 450 562 642 .7 na 98.60 Feet 100-10 Feet <br /> Capact VII INFORMATION in gallons Toalltal <br /> Tanks Manufacturer's Name ConcrePrefate Con- Steel g ass Plastic Aper. <br /> New Existin strutted <br /> Tank Tanks <br /> Septic Tank or Holding Tank 1000 --- 1000 1 JWieser Concrete ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 600 --- 600 1 Wieser comb. Q El El El 1:1 ❑ <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) JPI tier's Si natu (No tamps) r7P <br /> MPRSW No.: ?715-349-5533 <br /> usiness Phone Number: <br /> Donald Daniels 330/221593 <br /> Plumber's Address(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 Date Issued Issuing Agent S natur (N t ps) <br /> r-ftrApproved E]Owner Given Initial Surcharge Fee) <br /> Adverse Determination 6 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />