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Safety and Buildings Division Cowry R 201 W.W.Washington Ave.,P.O.Box 7162 <br /> eonsin Madimn,W153707-7162 Sanitary Permit Number(W be blbiin by Cu.) <br /> De ertment of Commerce (608)266-3151 *95 2i <br /> Sanitary Permit Application State Plan FD Number <br /> In mcmd xiU Comm 8321,Wis.Adm.Cade,personal Wformetion you proviJe <br /> meybeusWfmsmondmypuryoses PnvayUL sl5,oa(IXm) Pito AddressofdiRernothannniingaddrnes) <br /> 1. Application lafterreation-Please Print All lnformafion �J <br /> 1 M <br /> Owner's Namef� Percelq Lotp , Bl. W <br /> /...I4X + af'4 Ll d.[-a�;,t,s OLU - 9200- og 6300 <br /> Pomo er's Marg Address trotter,London <br /> X001 n.a - s-1, o <br /> City,Slatae(f Zip Code Phone Number -�-- �' Y., Satian <br /> �QN Wk �t yB3U %/,r-F3(a Ie- �BIIB TYV N, R�EameWa) <br /> IL'lype of Buil "g(check all that apply) <br /> Ulort Family Dwellin Number of bdiviaian Name CSM Number <br /> Vl Y 6- � C✓Sf uS {�I� �Otif <br /> ❑Public/Commemial-Fodbe Use CllOw //]<'arr <br /> 11 Slow Coosa-Nicnbe Use ElCily_❑village R1'ownship-QL K1Gti <br /> III.Type of Permit: (Check holy one boa on It..A. Complete It..B ifapplieabte) <br /> A ❑New SyneTrntomNBolding Tnnk Replacement Only IF](Mm Modification to Existing System <br /> B. ❑Penni Rm, Cl Person Revision ❑Changan ❑PermitTmmsferto New List Previous Permit Numberand Date Issued <br /> Before Expiration Plumber Come, <br /> IV.T eofPOWTSS tans: Chink all that apply) <br /> on-Pressurisd -Gi mnd ❑Mhmd>24 m ofsuimble,mI ❑Maun i'M m of,miable snil FlAl-Cminde ❑Single Pass SandFilter U <br /> ConstrmledWorland ❑ &enurird A-Gowd ❑Holding Tank ❑Pert Filter ❑Atomic TreatmentUna ❑Rwimulating Smm Filler ❑ <br /> Recirmiating Synthede Media Filler 21teaching Chamber ❑Drip Line ❑Ofavel-Ins Pipe ❑_Olber(explain) <br /> V.Die emVrmaimeut Arealnforma6on: —Cf S 3 'X --Ed a a s <br /> Design Fiow(gpL) Design Soil AW11mion Rate(gpdsf) DisPereal Area Reauimd(so Dispersal Are a Poposed(at) System Elevation <br /> 300 Yz 9 9,a. . 3 <br /> VI.'Finklnfs Cepmiy in Intel Number Manufacturer @dab Site Steel Fibs PlmGc <br /> Gallons (ielloms of Unita Concrete Conswned 01. <br /> NewEu <br /> Tnnka mnig <br /> Qginol°'na Tmik 00 rj 4 w <br /> Anomic Trenlmeol lint <br /> Doe'Chimed / <br /> VIL Responsibility Statement-1,the undersigned,resume responsibility for installation of the POWTS Amon on the hunched pons. <br /> P mbm's o) umSi, MPber's Sibin Business Ph one Number <br /> aNamc wyywK%n sZzzg7Z Y7z- L4z 1 <br /> Plumber's Atldress(Street,City,Smtq Zip e) <br /> b5-5 Sf. 1uc� � r SY853 _ <br /> VUL Chun /De rtment Use Only <br /> Approved ❑Dtmppoval 9artary Poona Fee(imcluJes(mmodwate, Dele Issued Tsui gent:'mm m Stomps) <br /> Suremerge Fee) rr� &O 7 el 6G_ <br /> ❑Owner Giem Ronson for Denial ff('d✓ <br /> IX.Conditions of ApprovalQ@asons for Disapproval <br /> Amos—plate has on the Calmly only)Por the I,.oro Pvpu-11—thimon a It lethee W Jin <br /> SBD-6398 (R. 01/03) <br />