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I _ SANITARY, PERMIT APPLICATION <br /> ti®ILHR COUNTY <br /> I _ In accord with ILHR 83.05,Wis.Adm.Code <br /> � r n s;l�I <br /> CG- <br /> ITARY RMITq�g <br /> -Attach cSTATEomplete plans(to the county copy only)for the system,on paper not less than 16118(] '1 Y <br /> 8h x 11 inches in size. ❑ check it remamm 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. X13-p�d <br /> PROPERTYOWNER - PROPERTVLOCATION <br /> A Y.., S T � ' , N. R IE o <br /> PROPERTY OWNERS MAILING ESS LOTq/YOV L- _rrLj_ BLOCK <br /> CITY,SS-T]lATE IL-11 s'-ZIINVPCODE PHONE NUMBER SU II-J L. <br /> DA i 30 ' U c <br /> II. TYPE OF UILDING: (Checkone) ❑State OWIn MY <br /> Detl DVILLAGE: ;ARE ROAD <br /> - ❑ PUBIC V<t1 er 2 Fem.Dwelling-hof bedrooms_ R L yAOF i <br /> X NUMBS on <br /> 111. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ ApVCondo ✓O ✓ - -/ -20 Assembly Hall 6 Medical Facility/Nursing Home ' 10 Ll 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 6 if applicable) <br /> A) 1. w.. 2.XReplacement 3. ❑Replacement of 4.❑ Reconnection of 5.❑ Repair of an <br /> _Vystem 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 E-1 Holding Tank <br /> 12 Seepage Trench 22 ❑ In-Ground 42 ❑ 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4.LOADING RATE 5. PERC.RATE� 6. SYSTEM ELEV. 7. FINAL GRADE j <br /> REO IRED(sq.tt.) PROP pSED(sq.tt.) (Gals/day/sq.ft.) (Mindinch). _ ELEVATION <br /> 39 O O p(7 �Z Feet Z-O Feet <br /> CAPACITY <br /> VII. TANK - - Site - <br /> in allons Total T#ofanks <br /> Prefab. Fiber- Exper. <br /> INFORMATION Manufacturer's Name Con- Steel Plastic <br /> New istln Gallons Tanks ncret strucled glass App' <br /> Tanks Tanks <br /> Septic Tank or Holdin Tenk <br /> Lift Pump TanVSi hon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation ofthe onsilesewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:( stamps)t MPIMPRSW No.: Business Phone Number: <br /> &AAK0 91)FXIN5 �lS 1571 <br /> umberh Address forest.City,state,Zip e): <br /> 2 1�� w 3S fZ W(. SI893 <br /> IX. COUNTY/DEPARTMENTUSEO LY <br /> ❑ Diupprovae Sanitary Permit Fee llrclWr Gro�Mwaty ae esu Issuing Agent Signature IN tarn ) <br /> Approved surcnergs F..) <br /> ❑ Gwner Given initial 13s.UD s-as-�3 <br /> Adverse Determination i <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-63g8(formerly Plb6T)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 6 Buildirps Division.Owner.Plumber <br />