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SANITARY PERMIT APPLICATION COUNTY <br /> P14HR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE ANITAR'''���''''''RRR���RMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than (15qa�) <br /> 8'fi x 11 inches in size. ❑ Check it revisW to previous application <br /> —See reverse side for Instructions for Completing this application. TATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. — a�U(�;I uZ <br /> PROPERTY OWNER PROPERTY LOCATION <br /> ICLwfA' C_30C. �t G d t n c 'CJ'/4 C Y4, S3� T V( N, R �� E (or <br /> PROPERTY OWNER'S M ILING ADDRESS LOT# BLOCK# <br /> �4 f F lf>v P141'. a.i Govt• LO-r <br /> CITY STATE * ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> !,36o <br /> IL TYPE OF BUILDING: (Check one) LJ State Owned Lj VILCITYLAGEAREST ROAD <br /> ��,�/(6,,,1 d! Pd <br /> ❑ Public 1 or 2 Fam.Dwellings of bedrooms NEC� �,t CV�� (A NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 110 Apt/Condo <br /> 2 ❑ Assembly HaII 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. ❑ New 2.1,X 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 /> tt <br /> 11 ❑ Seepage Bed 21 El Mound 30 ❑ Specify Type 41 la Holding Tank <br /> 12 ❑ Seepage Trench 22 ElIn-Ground42 ❑ 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 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> `.� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in gallons Total #of Prefab. Fiber- App. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name c ncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank o ..1d1n Ta %eS-4 - XIC AOk <br /> Litt Pump Tank/siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for in tallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Pr' t): Plumb is Signature:IN S pal MP/MPRSW No.: Business Phone Number: <br /> APES )e �Y ��� L✓ fL1PS7� 7/F <br /> Plumber's Address(Street,City,State,Zip Code): <br /> /'?Y�- ±� P �, cJ r 5��y3 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater Date IssuedIssuing gent Signature(No Stamps) <br /> Surcharge Fee) <br /> A roved ❑ Owner Given Initial (� (�) <br /> PP Adv rmintion ��./J' `�� <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/118) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />