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�. � SANITARY PERMIT APPLICATION ec . <br /> �•iE�iiRCOUNTY pp <br /> In accord with ILHR 83.05,Wis.Adm.Code Burnett L-/9G <br /> STATE SANITARY PE MI # <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than (/��I <br /> 8'/z x 11 inches In size. ❑ ChacTc if rAion to previous application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. S95-31235 <br /> PROPERTY OWNER Gov 0 PROPERTY LOCATION <br /> Joseph Lupo pcl in NW '/a SE '/a, S 2 T37 , N, R 18 /Oor)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 2.2180 Spirit Lake Rd E na I na <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Frederic WI 54837 715 689-2568 na <br /> 11. TYPE OF BUILDING: (Check one) CITY N pR r t Lake Rd E <br /> State Owned O CILLAGe:Trdde Lake <br /> ❑ Public KI1 or 2 Fam. Dwelling,#of bedrooms 3 PAR EL TAX NUMBER(S) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 034 - 1502 - 02 200 <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 ❑ 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 in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. x❑ 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 H Holding Tank <br /> 12 E1 SeepageTrench 22 F-1In-Ground42 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 16. SYSTEMELEV. 7. FINAL GRADE <br /> 450 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> na na na na I ndadaFkpt na Feet <br /> VII. TANK CAPACITY Site <br /> in aal Ions Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New ExistingGallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber <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 tier's Sig ature No Stamps) MP/MPRSW No.: Business Phone Number: <br /> nnnAld 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 AWIudes Groundwatera e s ue Issuing Agen ig re mps) <br /> Approved ❑ rcharge Fee)Owner Given Initial V/Ly <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DI APPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />