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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code CO NTY r <br /> EB <br /> MIT#v <br /> �o-1aC1 <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than STA --//ppESANITARYPA <br /> 8'%x11inches Insize. ❑ ch kiifrevisio� previousapplication <br /> -See reverse side for instructions for completing this application. �� STA E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PR PERTY L9CA ION <br /> JOhu &h.,,1-5 '% ''/a, S 3 T5y�N, R / r W <br /> PROPERTY OWNER'S MAILING ADDRESS LO'r# BLOC # <br /> CITY, TATE �'�l1� ky) ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 74C.0,V sa4 mA 'd �G3 5 3,7 <br /> IL TYPE OF BUILDING' (Check one) El State Owned CITY <br /> AGE S sT U <br /> ❑ Public or 2 Fam. Dwelling-#of bedrooms 3 A LTAX NUMBER( ) �` <br /> III. BUILDING USE: (If building type is public,check all that apply) ) -3 —0� —r 10 <br /> 1 ❑ Apt/Condo "7 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/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. TYPPEyOF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. L�'F-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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 14. LCADINGRATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIIRED(sq.ft) PROPOSED s sq.ft.) (Gals/day/sq.ft.) (Min./inch) 4 �EsLLEY TION <br /> 9.2-40 ° 77-0 p . &3 7-- % 7i Feet / J, Feet <br /> VII. TANK CAPACITY Site <br /> in gallops Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank <br /> Litt Pum Tank/Si hon 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' 'gn oStam s) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): / C <br /> 22-3/ S�— N�/?sn7 �iLl�s �d S/L^ ✓/f c U .s S 7 Z <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater )ate Issued Iss Ag ntsi ature(No Stamps) <br /> Approved ❑ Owner Given Initial �y�Ib- Surcharge Fee) XA <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,Own r,Plumber <br />