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Safetldis <br /> SANITARY PERMIT APPLICATION BureauaofBBuildingWaterDivision <br /> Systems <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 l <br /> than 8112 x 11 inches in size. Burnett AA /'To <br /> • See reverse side for instructions for completing this application State Sanitary Per Number <br /> 3 30 3'7� h <br /> The information you provide may be used by other government agency programs ❑Check if revision previous application <br /> [Privacy Law,s. 1 5.04(1)(m)]. <br /> State Plan I.D.NurrIber <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION 162834 d <br /> Property Owner Name Property Location <br /> Arnold Walker Jr 1/4 1/4,5 36 T46 N, R 15 /F/OJW <br /> Property Owners Mailing Address Lot Number Block Number <br /> 467 Mountain Dr I na <br /> Cit ,Statinburg TN Z1§Code Phone Subdivision NameorCSMNumber <br /> M <br /> CSM Vol 1 Pg 103 <br /> I1. TYPEXYF BUILDING: (check one) ❑ State Owned ❑ It� Nearest Road <br /> Public 1 or 2 Family Dwelling-No. of bedrooms 2 ❑ Vil age <br /> 01 Town OF Jackson Peninsula Rd <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 012 - 4236 - 04 - 300 <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 1 ❑ 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 /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate5. Perc. Rate 6. System Elev. 7. Final Grade <br /> 300 Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> na na na na holding t Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper <br /> New Existin Gallons Tanks Concrete con- steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank <br /> I7ft Pump Tank/Siphon Chamber ❑ El ❑ <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 Signature:( Stamps) 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 /> ❑Disapprove d Sanitar Permit Fe (includesGroundwater ate IssuedIssuing a ignat e( o ps) <br /> �pproved [:]Owner Given Initial hh is3 Surchargefee) <br /> Adverse DeterminationV/C� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD.6398(R.85/94) DISTR18UTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />