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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code ALJ BU I r/ - <br /> �.��...:,�...,e. CIV <br /> STATE SANITARY PERMIT#i q oq if s <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ( )5315a\/ <br /> 8'%x 11 inches in size. ❑ Check if revs6n 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. S'1CADI <br /> PROPEPPgER PROPERTY LOCATION <br /> ''/a '/a, S T N, R f E(orW) <br /> PROPERTTE 'S MAILING ADDR L # LOCK# <br /> Z1 5 u't. <br /> I ,STATElba IP CO PHONE NUMBER SUBDIVISIONQNAME OR CSM NUMBER <br /> ) <br /> LJ <br /> CITY - , NrEST ROAD <br /> IL TYPE OF BUILDING: (Check one) ❑ State Owned 22 VILLAGE <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms_L NUM ( ) l <br /> Ill. BUILDING USE: (If building type is public,check all that apply) L..L]_ a r D� 07-600 <br /> 1 ❑ Apt/Condo /v� J <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 in line A. Check line B if applicable) <br /> A) 1. ❑ New 2.XReplacement 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 Pre����s----s,,,,rrrru���rized Distribution Experimental Other <br /> 11 ❑ Seepage Bed 21Mound 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 PER DAY 2.ABSORP.AREA 3.AS RP.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 /> r FeetG(, ,•l7JLmt <br /> VII. TANK C PACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New isa Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks <br /> structed <br /> Sept c Tank or Holdin Tank n v <br /> Lift Pump Tank/Siphon Chamber <br /> Lr <br /> VIII. RESPONSIBILITY STATEMENT laal� <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 Sta psI MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Codl): <br /> Q- <br /> UJIL&SI2- <br /> /COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sent ry Permit Fee Ilncludee Groundwater a e ssue Is ing gent Sig re(No Stamps) <br /> eta} SuLud:largeFee) <br /> Approved ❑ Owner Given Initial cLl I�h <br /> Adverse Determination �\\kNNf ll <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />