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SANITARY PERMIT APPLICATION <br /> V IL fj�j COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> STAT SANITA$,S PERMIT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �� �q6-? <br /> 8%x11 inches in size. <br /> 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 LPROPERTY LOCATION <br /> Q ''/s, S T Q , N, R E (o WPR PERTY OWNER'S MAILING ADDRESS BLOCK# <br /> L 5-". <br /> CITY, ATE ZIP CODE PHONE NUMBER SION E OR C M NUMBER <br /> *KOZL• 7- 1 II. TYPE OF BUILDING: (Check one) NEAREST oAD <br /> State Owned AGE it _wAfb <br /> ❑ Public X 1 or 2 Fam. Dwelling-#of bedrooms3TAXNUMBER( ) <br /> III. BUILDINGUSE: (If building type is public,check all that apply) pa.p - C(�al- o31 cj) <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 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. TYPPE(OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. lXJ New 2. El 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 F1 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RErIREED(sq.ft.) PROPOSED(sq.ft. (Gals/day/sq.ft.) (Min./inch) 2 ELEVATION <br /> q-�" YJ �7 �p . . J Feet O Feet <br /> APACITY <br /> VII. TANK Ingellons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank DD <br /> Lift Pump Tank/Siphon Chamber F-1 El Ll <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No S mps) MP/MPRSW No.: Business Phone Number: <br /> cN g a ids - 7� j 66 1> <br /> Plumber's Address(Street,City,State,Zi Code): <br /> 76 o w 35 W STE2 1.11. SwI3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee <br /> (Includes, Groundwater <br /> Surcharge Fee) Ce ssued <br /> ng /LitL11'�1No rpproved ❑ Ownereal F( oGU <br /> AdverseDetermination: /t <br /> 1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB46398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />