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EDWaa SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Coder <br /> STATE SANITARY P MIT#)S l I4 L <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. ❑ Ch'eck if revialon 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. <br /> PROPER OWNER P RTY TION 1LQ 1 <br /> Ke '/4 '/4, S 3 T /, N, R -(r'E (or <br /> PR P I OWNER'S AING DESS LOT# '/� BLOC # <br /> CITY,STATE IL•r ZIPcQDE ON NU BEIR �/ rNU930 1 <br /> II. TYPE OF B ILDING: (Check one) toLi DI NEAREST ROAD❑State Owned W TOWN VILLAGEWt5Met Kf56 R9, <br /> ❑ Public 1 or 2 Fern.Dwelling-#of bedrooms� A x Nu ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) <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 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE <br /> j''OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.1+SI New 2. ❑ Replacement 3. El System <br /> of 4. [1 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 J�LSeepage Bed 21 ❑ Mound 30 ElSpecify Type 41 El HoldingTank <br /> 1 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.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> R IRhED(aq.tt.) PROPOSED(sq.tt.) (Gals/day/sq.tt.) (Mi ./inch) Q LEVATION <br /> 10 3q— e -I Q Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tankor Holdino Tank <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> bar's Name(Print): Plu bar's Signature:( o S ps) MP/MPRSW No.: Business Phone Number: <br /> IrlICAIRW (5 <br /> I lnber's Address(rv%Str e,C State,Zip CpW,d ): W5,s� . <br /> IIXJCOUNTYIDEPARTMENTUSE ONLY <br /> DisapprovedSanitary Permit Fee(Includes Groundwater Date issued Issuing Agent Sig ature o�. <br /> pprovad ❑ Owner Given Initial 10,= Surcharge Fee) <br /> Adverse Determination <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&Buildings Division,Owner,Plumber <br />