Laserfiche WebLink
Ar SANITARY PERMIT APPLICATION <br /> tvIn accord with ILHR 83.05,Wis.Adm.Code cou T�' Burnett <br /> STA $ANITAICY PERMIT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 1) <br /> ❑ I J\ <br /> 8+%x 11 Inches In size. heck if revision to previous application <br /> -See reverse side for Instructions for completing this application. STA E PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. 94-21172 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> VOYAGER VILLAGE POA SW % SW /4, g 7 T40 N, R 14 t/(kir) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 28851 KILKARE RD 60 - OA\oV na <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> DANBURY WI 54830 715 49-5533 Meadow Green Add. ' )r?El CITY � G 20 <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE NEAR ST ROAD <br /> Scott K'lkare Rd <br /> ® Public ❑1 or 2 Fam.Dwelling-#of bedrooms— PA EL TAX NUMB (S) <br /> k` S <br /> Iii. BUILDING USE: (It building type is public,check all that apply) VOYA 20 028 9350 06 - �VOYA 20 028 9325 02 500 <br /> 1 El Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ® Res aurant/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 in line A. Check line Bit 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# 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 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 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 /> 5964 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 12,780 12,780 .7 -- 97.8 Feet 101 .00 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank <br /> Lift Pump TanWSi hon Chamber 25001 — 2500 1 W 1 er <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 bar's Si na re:( StampI MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 715 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> PO Box 316 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> EJ Disapproved Sanitary Permit Fee(Includes Groundwater ate ssue Isis g nt ign ur IN Trips) <br /> Sa(eharge Fee) G <br /> Vf Approved ❑ Owner Given Initial O (�—,�� I <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />