Laserfiche WebLink
f" (Sn8uildin Divmon <br /> rn■ ■•� Bureau of Building Water Systems <br /> rte, nn SANITARY PERMIT APPLICATION 201 E.Washington Ave <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Boz 7969 <br /> Madison,WI 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 Statesanitary�mit Number <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)l. <br /> State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> r <br /> Property Owner Name Property Location <br /> David Bryan IL 11/4 14,S 20 T 40 .N, R15 /1fq+)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 2512 Euclid Place na I na <br /> Gtf,l llflea 011$ MN ZDb4�� Phone Number Subdivision Name or CSM Number <br /> p Db4 (612 ) 374-3280 na <br /> II. TYPE OF BUILDING: (check one) E] State Owned ❑ ity Nearest Road <br /> Vil age <br /> Public 1 or 2 Famil Dwellin - No. of bedrooms .— r Town Of Jackson County Rd "A" <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s) <br /> 12 42 20 01100 <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 T <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on llneA. Check box online B, if applicable) <br /> A) 1. ❑ New 2. a 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 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.Area3. Absorp.Area 4. Loading Rate 15. Perc. Rate 16. System Elev. 17. Final Grade <br /> 450 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 643 94.00 Feet 97.00 Feet <br /> TANK Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab Con- Steel Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank __ e 0 ❑ ❑ ❑ ❑ ❑ <br /> Ll ft 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 bels i natur :(No Sta ps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels I MP 330 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> PO Box 3.16 Siren WI 54872 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanita yPermit Fee (ln.ludeeGmvndwater ate sue Issuing Agent Si ature oSt <br /> A roved sur.nar9etee) <br /> opp ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR SAPPROVAL: <br /> SBO-6398(n.05/94) OISIRIBUTION. 01"..e11.1 Courly,One,, To_ Sutety&Bu.ldh,,Dim ,. ,Owner,plumGer <br />