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Ew <br /> .�� SANITARY PERMIT APPLICATION <br /> � In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STA ESANITAIQYPERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less thanE] kf� r �tlC) <br /> 8%x 11 Inches In size. heck if revision to previous application <br /> —See reverse side for Instructions for completing this application. STA E PLAN I.D.NUMBER <br /> I./qAPPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. 7 > /(/) <br /> PR <br /> PERTY OWNEo <br /> 4,11/. A19711., J 3 T t" , N, [ r <br /> PROPEERTYOWNE(R'S MAILING ADDRESS LOT# BLOC #M1f 7d ` <br /> I GIC <br /> CITY,STATE ` ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER d <br /> cc�pb 1cr 1 �5 s 7�s C-s-1 v 3 doh <br /> 13 CITY NEAR ST ROAD <br /> IL TYPE OF BUILDING: (Check one 1� <br /> l�7( ) State Owned ❑ VILLAGE JQWN QF' L -g A <br /> ❑ Public VNJ 1 or 2 Fam. Dwelling—#of bedroom PARCEL TAX N\\UMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) C.AV" C/_ <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 OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. N 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 PER 7 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> .-� <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.111 (Min./inch) Q 2 p ELEVATION <br /> v73 Z— - I Jr • Feet { 7 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisin <br /> Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank rHoldin Tank pU (.0 E'S2{ C.I-r Z <br /> Lift Pump Tank/Sipon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for I stallation of the onsite sewage system shown on the attached pans. <br /> Plumber's Name(Print): Plu er'sSi nature: o mps) MP/MPRSW No.: Business Phone Number: <br /> Pis / r �� u - -7.1 s �� <br /> Plumber's Address(Street,City,Stale,Zip Code), <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate IssuedIssuing Ag nt Signat r ( S ps) <br /> Ed Approved ❑ Owner Given Initial ' \surcne_ryq Fee) C _ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />