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17— m2 SANITARY PERMIT APPLICATION COUNTY <br /> DILHRIn accord with ILHR 83.05,Wis.Adm.Code <br /> STATES y�ITAR�PERMIT#'(1 57333 <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than / i� X) '1 <br /> 8'%x 11 inches in size. El ch k it revl ' n to previous application <br /> –See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. — U <br /> PROP RTY OWNER 4AYGE <br /> ERTY LOCATION <br /> ''!s'� '%,S'3L T N, R (c E (or(R) <br /> PROPERTY NER'S MAILING ADDRESS <br /> 3� uti T- I .>,. <br /> CIN,STATE 21P CODE PHIVISION NAME OR CSM NUMBER <br /> 71 �6IP.II. TYPE OF BUILDING: (Check one) ITYNEAREST ROA'Dr❑StILLAGE L f� �N►V ( _ RpPublic 1or 2 Fam. Dwelling,# L N UM8 ( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) aO— 13--3o( — O3---.CO <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 g ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Chet only one in line A. Check 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 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 /> 11 ❑ 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 PER7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REOUIRED(sq.ft.) PROPOSED(sq.ft.) I (Gals/day/sq.tt.) (Min./inch) EL NATION <br /> -300 1 Feet Feet <br /> CAPACITY Site <br /> VII. TANK <br /> in allons Total #of Prefab. Fiber- Exper. <br /> Manufacturer's Name Con- Steel Plastic <br /> New istin Gallons Tanks Concrete structed glass App. <br /> INFORMATION <br /> Tanks I Tanks <br /> Septic Tank or Holding Tank <br /> Litt Pump Tank/Siphon 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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> (ucR D }LOCK) s 31lz� 1 , SfoG �S'f <br /> Plumber's Address State, Cody! W&3SrZK L �4 `01f> <br /> r <br /> UNTYIDEPPA/�eRTMENTTUS ONLLY7 Jlr— gDisapproved Sanitary Permit Fee(Includes Groundwater ae ssue IssuingA n igna mps) <br /> Surcharge Feroved ❑ Owner Given Initial /`V1 6__�_q <br /> Adverae Determination l.�J <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />