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SANITARY PERMIT APPLICATION o0u <br /> TY <br /> Law, 116111111111111's In accord with ILHR 83.05,Wis.Adm.Code <br /> STA:,E ITA(IY PERMIT#�� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than �J\ '7\3c <br /> 8%x 11 inches In size. Check if revision to previous application <br /> -,See reverse side for Instructions for Completing this application. STA"E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTYOWNER PROPERTY LOCATION <br /> St WI Vi kLY4, S {o TN, E (orCW) <br /> PROPERTY OWNER'S MAILING ADDRESS Y LOT# BLOC # <br /> 7-116 ZINDIE.US 5T. <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> psc Eol_ l sjo za 7/5 )2-,14-3152 VOL. 289 <br /> El CITY <br /> IL TYPE OF BUILDING: (Check One) ❑State Owned VILLAGE SW ISS NEAR ST ROAD - <br /> c�� &ERR u <br /> ❑ Public X1 or 2 Fam. Dwelling—#of bedrooms z PAR ELTAx NUMBER(S) <br /> Ill. 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 ❑ Out oor 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. M 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 /> 11Seepage Bed 21 ElMound 30 ElSpecify Type 41 ❑ Holding Tank <br /> 12 6 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 72.ABSORP.AREA 3.ABSORP.AREA 14. LOADINGRATE 5. PERC. RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PR ?POSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Sob -z ; �7Z . 7 3-S Feet -1Q(p• Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons of Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank " C51—::W_ <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(Print): Plumber's Signatuxg;! <br /> MP/MPRSWNo.: Business Phone Number: <br /> lc P1<l05 ted <br /> P mtlb ' Address(Street,City,State,Zip Code). <br /> Z-1 7 60 NW4 3S W665P54W 1 , IL3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssuing g t natu o amps) <br /> � (�S rc rge Fee) <br /> ,leApproved ❑ Owner Given Initial h-��nt <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />