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0 �� <br /> to� � <br /> ' :•€s�„ Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System-. <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 812 x 11 inches in size. Burnett c267 17 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 300 � (a 8 <br /> The information you provide may be used by other government agency programs E]Check if <br /> [Privacy Law,s15.04(1)(m)1. revision to previous application- <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S97 - 20715 <br /> Property Owner Name Property Location <br /> Erwin Johnson SE 1/4 SE 1/4,S 32 T 37 N, R18 /Vldr)W <br /> Prop <br /> Owner's Mailin A drgss Lot Number Block Number 90MNorth nDrielson Rd na na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Luck WI 1 54853 (715 ) 648-5297 na 70 <br /> I1. TYPE F BUILDING: (check one) ❑ State Owned It� Nearest Road <br /> 2 ❑ Vilage Trade Lake Gabrielson Rd <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town OF <br /> III. BUILDING USE: (If building type ispublic,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0317 1532 - 02 500 <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. Q Replacement 3. ❑ Replacement of q ❑ Reconnection of 5. ❑ Repair of an <br /> _System _______System _______ - Tank Only---------------Existing System - Existing System <br /> B) E04 Sanitary Permit was previously issued. Permit Number ��b3 Date Issued—8D <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 Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 7. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> -1 TqQ <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 300 750 .4 na 104..9 Feet 106.9 <br /> Feet <br /> Ca act <br /> VII. TANK in gallons Total #Of Prefab. Site Fiber- Plastic Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name concrete Con- Steel lass A <br /> New Existin strutted g pp <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1000 -- 1000 1 Wieser Concrete El ❑ E] n <br /> Lift Pump Tank/Siphon Chamber 600 -- 600 1 Wieser COM !1 ❑ ❑ El ❑ E] <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 re:(N t mps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ox 316 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndudesGroundwater --r—ate-73=1 sluing Age Signatur (N tamps) <br /> roved Surcharge Fee) /� r <br /> pP ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 098(R.05114) DISTRIBUTION: Original to County.One copy To: Safety&Ruildings Dimsion,Owner,Plumber <br />