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SANITARY PERMIT APPLICATION COUNTY <br /> FILDWIR In accord with ILHR 83.05,Wis.Adm.Code d r n e <br /> �^-- -Z- STATE SANIT R PERMIT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ElCheck if revision to previous application <br /> a'%x 11 Inches in size. STATE PLAN I.D.NUMBER <br /> -See reverse side for instructions for completing this application. <br /> ;L O <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> ��- / '/a/� , '%,S T , N, R E(or <br /> / l e /O r LOT# BLOCK# <br /> PROPERTY OWNER'S MAILING ADDRESS <br /> 2 7 ✓C7 tea. <br /> CITY,S ATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 2. 7 NEAREST ROA <br /> 11. TYPE OF BUILDING: (Check one) ❑State Owned TILLAGE: e <br /> ElPublic -N 1 or 2 Fam.Dwelling-#of bedrooms A <br /> 111. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo 10 ❑ Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 11 ❑ RestauranUBar/Dining <br /> 3 ❑ Campground 7 El merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash <br /> 4 ❑ Church/School 8 El Mobile Home Park 13 ❑ Other: Specify <br /> 5 ❑ Hotel/Motel g ❑ Office/Factory <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) Repair of an <br /> A) 1. New 2. ®Replacement 3. 0 Replacement of 4.❑ Reconnection <br /> zls�9 System 5 Existing System <br /> System System Tank Only <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) Other <br /> Non-Pressurized Distribution Pressurized Distribution Experimental 41 Holding Tank <br /> 11 ❑ Seepage Bed <br /> 21 ❑ Mound 30 <br /> 11 Specify Type 42 ❑ pit Privy <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 43 ❑ Vault Privy <br /> 13 ❑ Seepage Pit Pressure <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> LOADING RATE ELEVATION <br /> 1.GALLONS PER DAY REQUIRED(sq.tt) PROPOSED(sgEtt.) 4 (Gal iday/sq.ft) 5 (M nPERC/inch)E 6. SYSTEM ELEV. 7. FINAL GRAD <br /> 3O � <br /> AIA <br /> CAPACITY prefab. Site Fiber- Exper. <br /> VII. TANK in allons Total #of Manufacturer's Name oncret Con- Steel glass Plastic App <br /> INFORMATION New istin Gallons Tanks strutted <br /> Tanks Tanks <br /> Septic Tank or Holdin Tank <br /> poo O 6v� / <br /> LIRPum Tank/SI hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans.Business Phone Number: <br /> Plumber's Signature:(No Sta pa) MPIMPRSW Nn.: <br /> Plumber's Name(Print): �� /O <br /> Yr -p r l/ C <br /> Plumber's Ad real(str. et, ity,State,Zi 7 <br /> Cod . �3 <br /> ILL 1� <br /> IX. COUNTY/DEPPARTMENT USE ONLY lssuin A nt Sign tura o S mps) <br /> DiseDProved Sanitary Permit Fee(Includes Groundwater e e esus <br /> Sur,Fharge Fee) - - q <br /> Approved ❑ RAq <br /> Owner Given Initial {)'h SSJ- O 4"1 -1 <br /> A v e D ermin tin -ii <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> One Copy To:Safety 8 Buildings Division,Owner,Plumber <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County, <br />