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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> _ mmma ZURtjt-rr- <br /> �• � STATE SI�NITARYP MIT#I��G,.,i <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than / /1���� ✓✓UJ <br /> 8'/z x 11 inches in size. ❑ Ch k i1 revision to revious application <br /> —See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROP PITY OWNER PROPERTY OCATION <br /> // (�C l� Y ''/s,S T N, R E (or <br /> PROPERTY O NER' MA ING ADDRESS / LOT# BLOCK# <br /> jjer <br /> C ,STATE ZIP C 830DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> - <br /> CITY NEAR TROAD <br /> IL TYPE OF BUILDINSa: (Check one) ❑State Owned VILLAGE' �' 4✓ Zion- <br /> 94 <br /> ❑ Public L}S�Jj 1 or 2 Fam. Dwelling—#of bedrooms� LTAXNUM O LLLYYY <br /> III. 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 ❑ Mbbil¢¢Home Park 12 ❑ Service Station/Car Wash <br /> 5 ElHotel/Motel 9 Elffic ZOctory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check 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-P essurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 ❑ Mound 30 El SpecityType 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 91 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSE?D(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �} /_ ELEVATION <br /> (QcJO 19 <br /> / 761 Feet 60 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New satin Gallons Tanks ancret glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank � T <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:lNo Stamps) MP/MPRSWNo.: Business Phone Number: <br /> Plurgpe�Add (Strset,City,Sfate, 1p � <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issug <br /> Approved gent Signatur (No Stamps) <br /> ❑ Surcharge Fee) <br /> Owner Given �} q' <br /> A v Initial /O 7 r� _�—S-C l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)(R.11/99) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />