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17— seseasel DILFIFI SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code cc rel( <br /> STATE SA)IIIT,ARIY PERMIT <br /> #13�sx.j <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �/T6�� <br /> 8'%x 11 inches in size. ❑ ch i revision to p vious application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S 9 " ,Dc' <br /> PR ER OWNE PROPERTY LOCATION <br /> l­-e(:1 �j� )G(J '/a ��'/a, S [�T 3�N, R / E-*Cw <br /> P9fERTY OWNER'S MAILING AQDR!f , LOT# , BLOCK# <br /> S/ �r� 6ou'�. CzTs a�3 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> of .� Z �t/Z P -s2 <br /> CITY o NE REST ROAD, <br /> IL TYPE OF BUILDING: (Check one) State Owned VILLAGE: J i!o!-P,-k <br /> o . <br /> ❑ Public N 1 or 2 Fam. Dwelling-#of bedrooms A AX NUMBER <br /> Ill. BUILDING USE: (If building type is public,check all that apply) _ oii`'6�yo <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. ElNew 2. N 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 El Seepage Bed 21 FJ 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 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> C) Ski S S Z: 3 -3._ ICO,. Feet 103 0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name bar- <br /> Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> e or Holdin Tank 7 ' esek- <br /> ik Pum Ta WSI hon Chamber "f' F <br /> VII . SPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for'nstallation of the onsite sewage system shown on the attached plans. <br /> Plumbers Name(P in Plu ber's Sigf ature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> K V (S �F k }�� fi <br /> Plumber's Address(Strest,City,State Zip Cove): / <br /> I COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved San tary Permit Fee(Includes Groundwater a e IssuedIssuing ant Signature(No Stamps) <br /> I'-J l.i D^surcnar9e Fee) I ._ <br /> Approved ❑ Owner Given Initial <br /> e <br /> Adverve Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11188) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />