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SANITARY PERMIT APPLICATION <br /> viL�in In accord with ILHR 83.05,Wis.Adm.Code couN Burnett <br /> E <br /> 71c, <br /> S9yIT�RY PERM�I�TC#. <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than J -'/y8'/s x 11 Inches In size. heck if revision to previous application <br /> -See reverse side for instructions for completing this application. STAT PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S95-30477 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Robert Webster 5 acr SE '% SW 1/4, S18 T 37 , N, 18 //l�M) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK <br /> 12800 County Rd 0 na na <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Grantsburq WI 54840 715 488-2780 na <br /> El If. TYPE OF BUILDING: (Check one) ❑ State Owned o CITY NEARE T ROAD <br /> VILLAGE' Trade Lake County "0" <br /> [] Public ❑x t or 2 Fam. Dwelling—#of bedrooms 3 PAR EL TAX NUM ER( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 34 - 1518 - 02 600 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outd or Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Rest urant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Sery ce 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 H Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 L1 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 7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC. RATE6. YSTEM ELEV. 7. FINAL GRADE <br /> 450 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 1125 1125 .4 na 101 .35 Feet 104.35 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin in Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holding Tank120 o12000 ' <br /> Lift Pump Tank/Siphon Chamber <br /> Vill. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu is Signature:(Np Stamps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels x �- 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 /> ❑ Disapproved Sanitary Permit FSurcharge F )Fee llncludes Groundwater a IssuedIssuing Ag nt Signatu ( o mps) <br /> nom! ee <br /> illy Approved ❑ Owner Given Initial <br /> w\ 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,Owl{er,Plumber <br />