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--� SANITARY PERMIT APPLICATION <br /> D R In accord with ILHR 83.05,Wis. Adm. Code C UNTY Burnett <br /> STTPERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than SANITA�N <br /> 6Ys%11 inches In SIZ@. Check if revi ion to previous application <br /> —See reverse side for Instructions for completing this application. ST NTE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Robert Mann _Gj} Y4 %4, S 25 T 40 , N R 17 /E, dv) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 8245 Park St W Baa W 6L ` I n <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Danbury WI 1 54830 715 866-4379 na <br /> F3 CITY <br /> II. TYPE OF BUILDING: (Check one) 11State Owned ❑ VILLAGE NEA EST ROAD <br /> n Union Park St <br /> [] Public 01 or 2 Fam. Dwelling-#of bedrooms. EL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 36 - 4425 - 01 600 <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 Bit applicable) <br /> A) 1. ❑ New 2. ® Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> ,,/System System Tank Only Existing System / xisting System <br /> B) LS^.ASanitaryPermitwaspreviouslyissued. Permit# -���� � Date Issued U /)qQa <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Ea 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 300 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 429 432 .7 -- 88.60 Feet 91 .60 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Astin Gallons Tanks Manufacturer's Name onca le Con- Steel glass Plastic App <br /> Tanks I Tanks structed <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Si hon 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): P bar's S',�,na����re:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> Do al D Ute% 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 Per I Fee(includes Groundwater Mare issuedIssuing Ag nt ignature( o lam s) <br /> Approved urc71 rge Fee) <br /> pp ❑ Owner Given Initial Ie. lurch <br /> Adverse Determination ���JJJfff � !n v <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Own r,Plumber <br />