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SANITARY PERMIT APPLICATION COUNTY <br /> �DILHR In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> �- STATE ITARY P MIT#,�b/8 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ITARY <br /> 8%x 11 inches in size. ❑ C heckitrevlsion previous application <br /> -See reverse side for instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S92-21161 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Jim Simons SE %S E %, S 15 T 38 N, R 14 /j�(/o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3800 Mangelson Rd na I na <br /> CITY,STATE ZIP CODE I PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Shell Lake WI 54871 715 468-7173 na <br /> CITY Dewe NEAREST ROAD <br /> If. TYPE OF BUILDING: (Check one) <br /> ❑State Owned VILLAGE: y Poquette Rd <br /> TOWN OF' <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 1 PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 008-2115-02-900 <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. [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 PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 450 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New ExistingGallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank <br /> Litt 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): Phu er's Signature'(No StarppsI MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels ✓n/�/C/'S MP 330 715 349-5533 <br /> Plumber's Address(Street,City,Stale,Zip Code): <br /> PO Box 316 Siren WI 54872 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee (Includes Groundwater I Date Issued I ng gent Signa (No Stamps) <br /> fy� <br /> Approved ❑ Owner Given Initial µl ��s.rpm Surcharge Fee) //.-3 <br /> Adverse Determination <br /> J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />