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Safety and Buildings ONiEi6n <br /> ` sconsin SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm_Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County Burnett <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> : a laS <br /> The information you provide may be used by other government agency programs E]Check it rev' Ion to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number- <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N N <br /> Property Owner Name Propert Location <br /> Jim & Jill Gloodt Nod 1/4 SSE 1/4,S 27 T 38 N, R 17 A/0)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> PO Box 6 b na na <br /> City.StteSiren WI zl��9�2 (Phone N 71!D ) 6-2067 Subdivision Name or CSM Number rid <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> VilPublic 1 or 2 FamilyDwelling-No.of bedrooms 4 Ri Town of Daniels Wood Creels Ra <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) 006 — 2427 — 02 700 <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/Motel 9 ❑ Office/Factory 13 ❑ Other: specify <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 _____________ TankOnly _______ ___ 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 ❑ Holding Tank <br /> 12 Ej 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> 600 Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 95,75 Elevation <br /> 750 763 .8 na Feet 99.50 Feet <br /> Ca act <br /> VII. N ORMATION in gallo s Total #of Prefab. Site Fiber- plastic Aper. <br /> Gallons Tanks manufacturer's Name Concrete CO" Steel glass App. <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1.250 -- 1250 1 1wieser Concrete 0 ❑ ❑ 1 ❑ 1:1 1 ❑ <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) PIu er's Signa ure:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels 221593 715-349-5533 <br /> Plumber's Ac dress(Street,City,State,Zip Code): <br /> PO Box 316 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved $pr(itaryPermit Fee (includes Groundwater atess Issuing ge Si tu (N S ps) <br /> XA roved yHw /✓/�RchargeFee) <br /> pp ❑Owner Given Initial l UPJ <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASO S FOR DISAPPROVAL: <br /> SBD6399(R.11196) DISTRIBUTION: Original to County,One copy To:Safety&Buildings Division,Owner,Plumber <br />