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2003/12/30 - SANITARY - SAN - Other - 22144
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2003/12/30 - SANITARY - SAN - Other - 22144
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Last modified
3/5/2020 6:12:32 PM
Creation date
10/6/2017 11:11:09 AM
Metadata
Fields
Template:
Property Files v2
Document Date
12/30/2003
Document Type 1
SANITARY
Document Type 2
SAN
Document Type 3
Other
County Permit Number
22144
State Permit Number
330373
Tax ID
2038
Pin Number
07-006-2-38-17-12-5 05-002-011000
Legacy Pin
006241202300
Municipality
TOWN OF DANIELS
Owner Name
SHERI & KENNETH NELSON
Property Address
8454 DANIELS 70
City
SIREN
State
WI
Zip
54872
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t <br /> e and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> tonin In accord with ILHR 83.05,Wis.Adm-Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> 0 Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. --�Zp;,) <br /> fill See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3-13 ICII <br /> The information you provide may be used by other government agency programs ❑Che c t r iston to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number , <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION 1 <br /> Property Owner Name Property Location <br /> S; ,� 114 1/4,S T ,N, R ZE(or W <br /> Prope y Ow er's Mailing A dr / L � Block Number <br /> �` 71 _– <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> i4U C/f}r/ Gcl <br /> 5-47'7c 3 ( ) <br /> II. TYPE OF BUIL DING: (check one) ❑ State Owned ❑ ity Nearest Rodd r <br /> El Public or 2 FamilyDwelling-No.of bedrooms a D Village <br /> pF PJ5 <br /> III. BUILDING USE: (If buildingtype is public,check allthat apply) Parcel <br /> �Tax Number(s) nn <br /> 1 ❑ Apartment/Condo '02P —Aglc ) _ 3W <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. M.New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> ----------------------------------------------------------------------------------------------- <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 9,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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> � e) �j d Z) s �� ""— �' � Feet X,/ Feet <br /> TANK Capact Site <br /> VII. INFORMATION In gallons Gallons Tanks ManufacturerTotal #of 's Name Concre a Con- Steel Fiber- plastic App. <br /> New ExiStin strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 0 7:5_O 4 0 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber $OG SC>0 I— ❑ ❑ ❑ I ❑ ❑ <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:(PrinuPlumber'sSignatur (No Stamp MP/MPRSWNo.: Business Phone Number: <br /> Plumber' Ac dress(Street,City State,Zjp Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate IssuedIssuing A e Signat rWoSmps) <br /> AA, ❑Owner Given Initial 1�0 surcharge Fee) <br /> NN Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> Ca80-6398(f3 11196) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />
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