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SANITARY PERMIT APPLICATION Co4 1933 1 <br /> ��Lar�6 In accord with ILHR 83.05,Wis.Adm.Code COUNTY rr <br /> TS 141" t <br /> STATE SANITARY PER,�7IT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �C�L/L� 1 Z <br /> 8%x 11 inches in size. &J Check if revision 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 /> C GOC.J h SW Ya k)6 %, S 9S T3rY, N, R I J E4er <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> qql se� 1 �o(< .4 <br /> CIN,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR��jC M NUMBER n <br /> W, Si, �avf IL ySS 776 -5InV,4 - <br /> IL TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE: / _ C NEA�EST�aoAS Q� �7 <br /> f(�� o w I �-�. <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms PARCEL AX NUMBERS) <br /> III. BUILDING USE: (If building type is public,check all that apply) ©//J 6 -�7C1 C) <br /> 1 ❑ Apt/Condo 7 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/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# 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 ❑ 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 /> `� <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (M�in./ins/In ,/ p ELEVATION <br /> `)0 C) 14 7- 3 z-- r l/ `(, S Feet /. -I Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Se ticT kor Holding Tank (.l1 PS-PY C <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fo installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Pr I: Plu ber's Signature: No ps) MP/MPRSW No.: Business Phone Number: <br /> S cS� 14Q R <br /> lumber's Addie (Street,C11Y,Stat Zip Code), f <br /> ?k( S__ Lr, <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ...���yyy��� ❑ Disapproved Sanitary Permit Fge (Includes Groundwater ate su Issuing A t nat Stamps) <br /> i� proved ❑ Owner Given Initial )/ �Y�J Surcharge Fee) <br /> ( Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />