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_ �i en �, <br /> Safety and Buildings Division <br /> �,ro., SANITARY PERMIT APPLICATION Bureau of Building Water System' <br /> .. ...+ <br /> 201 E_Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code 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 j <br /> than 8 112 x 11 inches in size. Burnett <br /> • See reverse side for instructions for completing this application state sanitary Prmit u <br /> The information you provide maybe used by other government agency programs E]Check it raevision torr//p/revioouss application Q <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S 9(0 — I oZ�a` lA <br /> Pr perty Owner Name Property Location <br /> Devin Karge SW 1/4 SW 1/4,S 18 T38 N, R17 IV(90 W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 10511 State Rd 70 na na <br /> Ci State Zip C P Nu b r Sud I Ion m CSM Nu ber <br /> Sri ren WI X72 (�� ) b°8�-2635 Von �� pg 9 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑❑ It( Nearest Road <br /> Ea Town Daniels Hwy 70 <br /> Public E] 1 or 2 FamilyDwelling- No.of bedrooms Town of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 006 - 2418 - 04 200 <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/Mote[ 9 ❑ Office/Factory 13)E] Other: specify taxidermy Shan <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 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System --------System __ _ Tank Only __ __ _ Existing System __ _ExistingSystem <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 [X] 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. Fina[ Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min/inch) Elevation <br /> 322 n I na na I na na Feet na Feet <br /> Ca acit <br /> VII. TANK in gallons Tota[ #ofMturer's Name Prefab. Site Con- Steel Fiber- Plastic Exper <br /> Manufacturer's INFORMATION New Existing Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 2000 -- 000 1 W1 Ser concrete El F] 1:1F1 1 <br /> Lift Pump Tank/Siphon Chamber Ej ❑ ❑ 1:1 0 ❑ <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 Si n ore o 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 WJ 54872 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> El Disapproved Sanitary Permit Fee ('SurchargeFendwater r;;7(0 ssuingAg tSi ( amps <br /> roved Surcharge fee)pp ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-6398(R.05/94) 1716iRIRUTION: Original to Cocmty,One copy To: Surety B Ruilaings nm,,on,Owner,Plumber <br />