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1110%; ;,, SANITARY PERMIT APPLICATION <br /> �'LFIR In accord with ILHR 83.05,Wis.Adm. Code cou 4TY Burnett <br /> STA :�SANTA PER IT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ IXCU 3 # D <br /> 8%%11 inches in Size. heck if revieien to previous application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. S)5-30263 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> John Zimmer NW % SW % S 19 T 40 N 17 /El�d� W <br /> PROPERTY OWNERS MAILING ADDRESS LOT# BLOCP # <br /> 11551 12th Ave 2 na <br /> CITY,STATEZIP CODE PHONE NUMBER SUBDIVISION NAME OR C M NUM <br /> Burnsville [ 55337 612 894-4044 -41&- ��� �� <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned LJ CITY❑ VILLAGE NEAR ST ROAD <br /> ❑ Public ❑x 1 or 2 Fam. Dwellin 3 Union County "F" <br /> g-#Of bedrOOmS— PAR EL TAX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) -;ww O3c4_c 1 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Rest uranVBar/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 B if 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 x❑ 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 DAI 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. YSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/da /s (Min./inch <br /> ) <br /> 450 643 643 q ft.) -- 98.00 ELEVATION <br /> Feet 1 101 .00 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper <br /> INFORMATION . <br /> New xistin Gallons Tanks Manufacturer's Name Concrete Con- teel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank IUULI -- <br /> Lift Pump Tank/Siphon Chamber 6nd __ 6no 1 combo <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 bar's Signature:(N S 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 /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a a ssue Issuing g n igna ur ( Stamps) <br /> Approved ❑ Owner Given Initial <br /> surcharge Fee) <br /> Adverse Determination <br /> 3�3a-"(A <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owns ,Plumber <br />