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0>1 cam <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNI Y <br /> 1 <br /> STATU SANITRYPERMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than I \ c) <br /> 81/2x 11 inches in size. ❑ ClPeck it revision to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER j <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> cflucf< o'j <br /> ADD % '/s, S T , N, R LI E(O W <br /> PROPERTY OW ER'S MIIL� LOT .�- BLOCK <br /> %glis- 14 <br /> CITY,STATE TTIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Cairn E E Assoi 6 z <br /> LJ It. TYPE OF BUILDING: (Check one) CITY NEARE T ROAD <br /> �j ❑State Owned ❑ VILLAGE S D - <br /> ❑ Public K1 or 2 Fam. Dwelling,#of bedrooms PA E—L T\AX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) /' 11 �'I lQ — 0 1- <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdc or 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.RReplacement 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 /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El 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 13.ABSORP.AREA, 4. LOADING RATE 5. PERC.RATE 6. YSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft. (Gals/day/sq.ft:.) (Min./inch) ELEVATION <br /> 300 LfZ� 3Z 7 ^— Feet z.- Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Man f ct�er'�Name oncrete–Con- feel glass Plastic App <br /> Tanks Tanks -A WW strutted <br /> Septic Tank or Holdin Tank 000 <br /> Lift Pump Tank/Siphon Chamber Wn I A I EM 1P <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pie ns. <br /> Plumber's Name(Print): Plumberure:(Np S ps) MP/MPRSW No.: Business one Number: <br /> A&J 3q7-6. I5 )%b-051 <br /> Plumber's Address(Street,City,State,Zip Code <br /> .55 1E8S(FK I . 5►�$g3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater r Use=ssuelssuingAt ignatu a St ps) <br /> Surcbage Fee) 1pproved Owner Given Initial /0 VtJ / <br /> AdverseDetermination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Own r,Plumber <br />