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SANITARY PERMIT APPLICATION <br /> r^�,t•Lt1RCou TY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STA SANITARY RMIT#�� IS-1 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than El �g 7 D 17 I <br /> 8'%x 11 Inches In size. heck if revisio to previous 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 /> PROPERTY OWNER PROPERTY LOCATION `/ <br /> �t� HAgp -! R C• u-It1/4 '/4, S t) T y1, N, R kK—E (ori <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# I ` BLOCK# <br /> SZ3 ZN n d <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR C M NUMBER <br /> �� W� • s Z$ ��is - cam-, �� <br /> IL TYPE OF BUILDING: (Check one) ❑State Owned ❑ VILLAGE NEAR ROAD <br /> �OWN OF <br /> ❑ Public .41 or 2 Fam. Dwelling-#of bedrooms— PAR EL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo U <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Rest urant/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. ❑ 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# r3a!5aj Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 ElMound 30 El SpecifyType 41 El HoldingTank <br /> 12 Seepage Trench 22 ElIn-Ground42 El Pit Privy <br /> 13 E, Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER 7 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED sq.ft.) (Gals/dL�y�/sq.ft.) (Min./inch) ^'� GELEVATION <br /> CT t:g' ( Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- feel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank 1 ML <br /> Lift 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(Pri ):/�) / Plumber,'p Signature: Sta s) MP/MPRSSW/No.: Business Phone Number: <br /> umber's Ad re (Street,City,State,Zip C de): <br /> 3_:!� t_� Xf <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved ISanitary Permit Fee(Includes Groundwater r ae ssue Issuing Aye it Signature(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ <br /> Owner eDetermin IC� <br /> Adverse Determination /J co�-'lJ / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB0.6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Own r,Plumber <br />