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Iff�; a;r, SANITARY PERMIT APPLICATION COUNTY �� '%7 o <br /> z� In accord with ILHR 83.05,Wis.Adr+t.Code <br /> T>u rive- <br /> (4-STATE SANITARY PERMIT <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ �[ <br /> 8'%x 11 inches in size. d a <br /> Checkif revisi n o 8 <br /> previous application <br /> –See reverse side for instructions for completing this application. ff STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. PGJI (1 LOl S — <br /> PROPERTY O NER PROPERTY LOCATION LL// <br /> Dqv"a L. G �CL 4 /, S 7 Tj , N, R E (Or W <br /> PR PERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> bOa O`1 U2 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAM OR CSM NUMBER <br /> fallsWi <br /> If. TYPE OF BUILDING: (Check one) State Owned VILLAGE <br /> Ej CITY NEAREST ROAD <br /> S I S /_ J <br /> v <br /> ❑ Publictai 1 or 2 Fam. Dwelling—#of bedrOonI AR EL AX NUM ER( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 0 g— 07 <br /> 1 ❑ Apt/Condo C <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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. X Replacement 3. ❑ Replacement of 4. E 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 Experiment al Other <br /> 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 N 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.;, 33 <br /> SYSTEM ELEV. 7. FINAL GRADE <br /> [�..�/r REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft. (Min./inch) p ELEVATION <br /> L 0 f 2 -S + "—'— Feet 11 / ,7S Feet <br /> VII. TANK CAPACITY <br /> in allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Nam Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Se ticT korHoldin Tank 1 IP <br /> Lift Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage systems iown on the attached plans. <br /> Plumber's Name(Pr nt): Plu ber's S' nature (No tamps) MP/MPRSW No.: Business Phone Number: <br /> (S �f r 7� <br /> Plumber's Address(street,City,State,Zip Code): / I - <br /> 7RVS— (fou c{ ,062 , S sl-f, <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a ss a Issuin ant Si to Stamps) <br /> Approved ❑ Owner Given Initial 56 �i surcharge Fee) �// <br /> Adverse Determination <br /> X. CONDITIONS OF PPROVAL/REASONS FORDI PPROVAL:, <br /> /'C1(l1/7 e_C dMe0- <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />