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SANITARY PERMIT APPLICATION ' <br /> COUNTYl:��rtaln In accord with ILHR 83.05,Wis.Adm. Code Burnett 5�) <br /> STATE SANDY P )iT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than LL�� J <br /> 8%x 11 inches in size. ❑ Check if revision to previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D. UMB <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Barbara J Shocinski % y., S24 T 40 N R 15gl(bpW <br /> PROPER CamdenSAveNPADDRESS LOT# 5 BLOCK# na `1 <br /> CITY,STATE f fVV ZIP CO PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Brooklyn Center MN 554�3�0 __ CSM V6 P9 rt lot 4 CSM V6 9 on �o�'t_, � 4 <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned o VI LLAJacksonM TOWN OF: I TM TRgonner Lake Rd <br /> [] Public 0 1 or 2 Fam. Dwelling—#of bedrooms 2 PARCEL TAX NUMBER(S) <br /> 111. BUILDING USE: (If building type is public,check all that apply) 012 - 4224 - 04 510 <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. 0 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 ❑ 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 F72.2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.I .) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 429 1 432 -7 na 1 95-00 Feet 98-15 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank -- 750 1 Wieser Concrete <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): Plu er's Sig atur o Stamps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels 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 Groundwatera e s e Issuing Age ignat e( t ps) <br /> / ( urcharge Fee) / {/y� <br /> Approved ❑ Owner Givenlnitial56 <br /> "�J7/C` <br /> 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,Owner,Plumber <br />