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SANITARY PERMIT APPLICATION <br /> COUNTY <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> STATE�SANITARY PERMIT# �-Attach complete plans(to the county copy only)for the system,on paper not less than ,'�j�a�8'%x 11 inches in size. ❑ Chk if revision to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S94-20595 <br /> PROPERTY OWNER PROPE TY LOCATION <br /> Township of SCott NW '/a NE ''/s, S 21 T40 N, R 14 /g Xgr) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 28390 Countr Rd H na na <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Webster WI 54893 7156 -6 6 na <br /> CITY NEAREST ROAD <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE'. Seott Ct A & H <br /> R1 Public El1 or 2 Fam. Dwelling-#of bedrooms— ALL <br /> R TAXNUMBS (S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 0 y�� _1) 00 <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 ❑ 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 PER DAI <br /> 2.ABSORP AREA 3.ABSORP.REQUIRED(sq.ft PROPOSED AR(sqEA)4 LOA(GalsDING RATE.ft.) 5. PERC.RATE <br /> E 6. SYSTEM ELEV. 7' FINAL G ONDE <br /> 586 837 840 .7 na 101 .00Feet 104• Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> T Tanks strutted <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): Plu er's Signatu e:(No amps) _ 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 WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ae ssue Issuin A nt Signatu (No Stam ) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial }y 1��.� —Ctq <br /> AdverseDetermination _y <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division.Owner,Plumber <br />