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.. <br /> SANITARY PERMIT APPLICATION Sa Bureau <br /> Billing ateri Division <br /> Bureau of Building Water S <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 8 1/2 x 11 inches in size. Burnett (oUGJBJ� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number �. <br /> 3030 <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application 1 ^ <br /> [Privacy Laws. 15.04(1)(m)]. V 11 <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Pro erty Owner Name Property Location <br /> Donald Truesdi l l GL 2 1/4 1/4,S 5 T38 N, R 15 /VXor)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 81 County Rd F 1 na <br /> City„1Ver Falls WI ZV822 ��� N4L���0263 SubCdsviion Va1gorP9 Number <br /> tt �7 b J1-� oZ <br /> II. TYPE 6-F-BUILDING: (check one) ❑ State Owned ❑ cit Nare t Road <br /> Public x 1 or 2 FamilyDwelling-No.of bedrooms �— Town of t-dFol Tette /�nc�lor Inn Rd <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 014 - 2205 - 03 110 <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 - --- -- - Tank Only---------------Existin System Existing System <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❑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 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 /> 643 643 .7 na 97.50 Feet 100.8 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Conite- Fiber- Plastic Exper <br /> New Exist Ing Gallons Tanks Concrete Steel glass App <br /> structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1000 -- 1000 1 Wieser Concrete ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 600 -- 600 1 Wieser comb ® ❑ ❑ ❑ ❑ ❑ <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) PI bet's Signatu re:( oStamps) 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 /> El Disapproved Sanitary Permit Fee " "Odes Groundwater Datessue Issum Ant5i atu (N Stamps) <br /> pproved ❑Owner Given Initial nargeFee) <br /> Adverse Determination19-17 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> D-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety&Ruildings Divwon.Owner,Number <br />