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SalLn and Buildin-;Di%i,ion Gmm. <br /> 11111 1Ca5hlnytonA%e. P0 Bo 'In_ aurnet� <br /> I V cOnV/I I M.IJiiun. 11'I 53'1l' - "I O_' SJnilar'• P;nlln �wuhtr Iw be tillyd in b:G1 <br /> Department Of Commerce 008),hh t-3151 <br /> Sanitary Permit .application Wa1e Plan IDD N°nlber 00 <br /> In accord with Comm 83 2I.U ti.Adm.Code•peraonal mGmnation you pro:ide <br /> may be used for sco,ndary purposes Pm icy Law.;1 5 11411 11111) <br /> Pngcct AJJrcu nfdiikrem Than nlaihng aJJreul <br /> I. application Information-Please Print All Information <br /> Pnrpcny Owncr s Nan1c ` <br /> Rangy Parcel a Lot a' Hloek a <br /> n _ <br /> Properly Owntri AlJdmg Address 0'16 933-p 0,1160 <br /> 960 Properly Location <br /> h11y.Stitt <br /> Zip Code Phone Number _'•. Section r0 <br /> ka i 7f1/V SSY33 �3 _ 7dty-d 3r\/ (aide one) <br /> 11.Type of Building(check all that apply) T qO N. R/0E o<5 <br /> 2 1 or]Family Dwelling-Number of Bedroom; Subbdi% ;wnName D CS,SI,'cumber <br /> 11Public Commercial-Describe Ate LOT I I P/aE 14 �tVP�fside <br /> ❑Slate Owncd-Describe Use ❑City_❑Vdlage Township of 6#&jA. <br /> Ill.Type of Permit (Check only one box on line Complc[e line B if applicable) <br /> El New System C1 Rep lacemem System ❑ Treatment Holding Tank Replacement Only 13 Other Modification to Existing System <br /> 9. ❑ Pontin Renewal ❑ Permit Reslswn <br /> ❑ Change of ❑Pei Transfer to New Lut Prevww Permit Number and Dam Is;ueJ <br /> Before Expiration Plumber <br /> Owner <br /> 1\'.Ts a of PO\\TS Ssstem: Check all that al3pivl <br /> Non-Pressurized In-Ground ❑ Mound>24 in.of wilable sod ❑ Mound<24 inof>uitable soil ❑ At-Grade <br /> ❑ Single Pass Sand Filler U <br /> Cumoucted Actland ❑ Preswn[ed In-Ground ❑ Holding Tank ❑Pcat Filter ❑ Aerobic Treatment Unit Cl Recirculating Sand Filter ❑ <br /> Recirculating Synihcnc\ledw Filter ❑Leaching Chamber ❑Drip Line ❑Grose)-kis Pipe ❑Other(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow Igpol I Design Sud Application Rotel gpd;Il Dispersal Arca Required(it) Dispersal Arra Proposed Iso System Elevation <br /> SSD a _7 6q* 6q a7 ?3.0 <br /> %7.Tank Info Capacity in Total Number hlinufaciufer <br /> Gallons Prefab site Steel Fiber Plastic <br /> Gallons of Units Concrete Constructed <br /> New Existing Glass <br /> Tanks Tanks <br /> Septic or HulJmg rank <br /> /000 /0 470 Ski w <br /> Aerobic Treatment Unit <br /> Doming Chamber t <br /> \ll. Responsibility Statement- 1.the undersigned,assume responsibilitv for installation of the POvvTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature <br /> 1 --// All AIPRS Number Business Phone Number <br /> /CrG/C �70 klr _r <br /> Plumbtr'i Addrci;(Street.City,State,Zip Cadet <br /> 'Ill.CounhvDe artment Use Only <br /> Appro%cd ❑ Disapproxed Sanitary Permit Fee line odes Groundwater Date Issued Iss• g A 1 Signat e u Stamps) <br /> Surcharge Feel P <br /> ❑ Owner Given Reason for Denial <br /> 1\.Conditions of.1pprovaUReasons for Disapproval 7 <br /> .Attach complete phot Ito the Counh only 1 fur Ilse system nn paper nut Ica then all a 11 iMAas ie siae <br /> SBD-6398 (R. 01/03) <br />