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0y)C <br /> SafetyandBuilding Division <br /> c�:p7rn; SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code Madison,oox 969WI 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 /> • See reverse side for instructions for completing this application State Sanitary Peerrmitt Number <br /> The information you provide may be used by other government agency programs ❑Check it revision to pre✓ous application <br /> )Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number QA <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S97-20571 /�/ / <br /> Property Owner Name Property Location T 38 r Nr R 18 /y YET)W <br /> John H Samuelson S/t p <br /> 2 NE 1/4,S10 <br /> Proa ner's Mailin Address Lot Number Block Number <br /> YMT County td I'MII , na I na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Grantsburg WI 1 54840 ➢1 ) 689-2321 na <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ village Wood River County Rd M <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms �_ Town OF <br /> III. BUILDING USE: (if buildingtypeispublic,checkallthatapply) Parcel TaxNumber(s) <br /> 042 - 2510 01 400 <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. V] Replacement 3- ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System ______ ExistingSystem <br /> ------------------------------------------------ <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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> 450 Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 643 643 1 -2 ( _7 nA 98.6 Feet 100-6 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con_ Fiber- Plastic Exper <br /> INFORMATION New Existin Gallons Tanks Concrete strutted Steel glass App. <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank 100o __ ® 1:1 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber Finn __ ❑ El El D 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 er'sSi na tur No S mps) MP/MPRSW No.: r7"15-349-5533 <br /> ness Phone Number: <br /> Donald B Daniels MP 330 <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 P it Fee (Inciudes Groundwater ate ssue Issuing A nt Si ature(No S <br /> charge F e) <br /> pproved ❑Owner Given Initial �{{l./y1 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL. <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: safety&Buildings Division,Owner,Plumber <br />