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commerceml.gov Satiety and Building,Di,'ion County ---- <br /> 201 W. Washington Ave- P.U. Bo,7162 �y/ 1v �� <br /> iseonsin Madison,W1 53707 7102 Sanitary Permit Nnnict(tm be filled in by Co.) - <br /> Dopartment of Commerce 4865,95 <br /> Sanitary Permit Application stale Tra"xacli"n NonJw— Ivr ----- - <br /> In accordance with s.Comm.83.21(2),Wis.Adm.('ode,subn.is,ion ol'thu tbnn to the epprvprialu goy'cnmwnlal � \�„1 <br /> unit is required prior to obtaining a sanitary permit. Nolc: Application Juno, Ile stole-owned Po\\'I.4 arc Project AJdress(if Ail7i:ronl than moiling addrcvs) --- <br /> submitted to the Department of Commerce. Personal inti nnalion you provide nlav be used for sccnndary �. <br /> purposes in accordance with lire Privacy Law,s. 15.04(1)(m),Stat,. �r <br /> 1. Application Information-Please Print All Information �- -_ - <br /> -- <br /> Property Owner's Name Parcel N UA <br /> !� e- VT's ( 0-7 07-032-2'41-I -30-10'{ - ?l <br /> Ivoperty Owner's Mailing Address property�Q operty Location P c s. <br /> rH '(a <br /> 4( g -- -- <br /> CiN.Stale Zip("ode Phone Number <br /> e er <br /> IL 7\pe of Building(check all that appl)) Lel i N; It j 770 w <br /> 1p�lor 2 Fmuily Dwelling-Numhcr ol'IscJroonls -7 Subdivision Name <br /> Block n <br /> Elmm <br /> I'ublic/Coercial-Describe t1.c — <br /> - ❑ City of _.... <br /> ❑Stale Owned-Duscribo UscCSM;' untbcr ❑ Villageof l— _ <br /> ,".Town of--� �l.'-�./.mss <br /> 111.Type of Permit (Cheek only one box on line A. Complete line II if applicable) _-�- <br /> \ �-New -- <br /> System Replacement ❑ 'ITalcLllnlJing''ank Kuplaeclel In11 ❑ Older Alodiicalinn to Existing Sysurlcgainl <br /> 13. ❑ Permit Renewal ❑ permit Revi,ion ❑ ('hangculllwnbcr El Permit hrNov <br /> t - List Previous permit Number and Dale Issued —_-- <br /> Bclitru Expiration Uwnc. <br /> W.•fv a of POW'PS S stem/Coal orient/Device. Check all that a t Iv),jC --_-� <br /> Non-Pressurized ht-Ground ❑ Pressurizcd In-Grand ❑ Al-Oridc ❑ Mound_24 in,otsuitablc soil ❑ Mound, 24 in.ol'suitable soil <br /> ❑ Ilulding'fnnk C1 Other Dispersal Clout xmcnl(o,plain) _ _ _ ❑I}cpe;rtinnit <br /> V.Dis ersal/rmahllent Area Information: _-- <br /> Design plow,(gpd) Design Soil Application Rale(gpJst) Dispersal:\rex Required(sl) Disposal Area[Imposed(,Q System P7eon —.-- <br /> 360 1 -7 % S 5. 0 <br /> VI.Tank Info Capacity in 'I'olaI a of hlanut:mturcr - - <br /> w <br /> Gallons Gallon, llnilx <br /> Ncw'lank. hxiwing'I anks --- `u c (u �` y b w <br /> U U rn ii C7 0.. <br /> Septiclx I lolding'look ':F0 <br /> VII. Responsibility Statement- 1.the undcr,igned,assumc v%pon,ibility lin in alallation of ole 110\\I h shown nlr the all itch ttI plans. „-- <br /> Illumber's Name(14Plumber's tiignalurc -i�%yc_s M1IPiA1PRS Nmnhcr Business Phnnc Numh—r <br /> j/'cJ inlh -_ <br /> Plumber's Address(Street.City,Slate,Zip Code) <br /> Zell <br /> Vlll.Counh'/De artment Use Ooh' <br /> y 1'crmil Pec Dale Issued Issuing. g t •ignalure / <br /> NJ .Approved ❑ Disapproved <br /> ❑ Owner Given)season for Denial S b 07 <br /> _-_ <br /> IS.(Conditions of Approval/Reasons for Disapproval -- ---- --- <br /> G 5(q AS1j0#h) r- FlaveA �Arct-I *: 03Z- 543(o -01 WO <br /> Atlaeh to cumpiete plass for the syalem and nuWnil Now County only on pu1Mr not Ire thou a trs s 11 hwlra Ill size _--- <br /> S13D-6398(R.01,07)Valid thru 01,09 <br />