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`� A <br /> Sit el and t es DI o, <br /> s `Ill ��. � ashloL;Ioll UII A\C P.() Bf3t1\ 'ICI consin Mddwm. ,kI <br /> Department ofJaniWr'-II'r_nnit,N um lire o be tilled in b:(_o I <br /> Commerce nus 1 2nn-;ISI It <br /> , I r 5 74,g <br /> Sanitary Permit Application $' ° ''1,11i ID Number <br /> Int xcord with Comm S3-'I,ills Adm.Code,personal mLtnnduon you prm ulc <br /> may be-,ed for,ccondary puTous Pm acy Law.,s l?JJI I I(1n) <br /> Prayed AJJrcu til Jt l(er;fl�arl I',ailing aJJresil <br /> I. :aC,.�I <br /> pplication Information-Please Print All Information I oz3 <br /> Pntpeny Owner's Name <br /> o � `� Nan��r Tree of <br /> Parcel a Lot,a Block o <br /> Propel. Owner's Alatling AJJrcss — 1ItSO+al,(7 —3 <br /> 7ek 06 Property Local on <br /> city.$lane SC N w <br /> Lp Code Phone Number •. Section /0 <br /> Cti+s o C;t M Al SSol3 (Ari-dsT- 3760 <br /> 11.Tspe o(Buildin (circic�) <br /> g(check all that apply) T 40 N. R /r E o <br /> �I or 2 Family Dwelling-Number of Bedrooms of <br /> Subdntitun Nam• �C AI Number <br /> ❑Public Commercial-Describe Use �Ct✓ ��� Ad�3 <br /> ❑Slate Owned--Describe Use <br /> ❑Cny_❑VJlage®Township of 0.6C'9Drt <br /> III•Type of Permit: (Check only on <br /> A e bot on line:x. Complete line B if applicable) <br /> XNe\v System ❑ Replacemem System <br /> ❑ Treatment Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B• ❑ Permit Renewal <br /> ❑ Permit Rev bion ❑ Change of List Previous Permit Number and Date Issued <br /> Before Expiration S ❑Permit Transfer W New <br /> Plumber Owner <br /> I�•Tv c of PON TS Svstem: Check all that a Ivl <br /> XNon -Pressurized In-Ground ❑ Ma-nd>24 inof,unable sod ❑ Mound<24 In.o(,uuable sod ❑ At-Grade ❑ Single Pass Send Filter LJ <br /> Constructed'A ciland ❑ Pressurized In-Ground <br /> ❑ Huldmg Tank 11 Peat Filter ❑ Aerobic Treatment Unit <br /> Reclrculaunq'"'"c Media FilterEl Recirculating Sind Filter <br /> ❑Leaching Chamber Cl Drip Line ❑Graxrl- -� <br /> �'. Dis crsal/Treatment Area Information: I"'p'Pe ❑Other(explain) <br /> Design F13.Igpol Design Sud Application Rate(gpdsn Dispersal Arca Rryured Ist� Dispersal Arra Pru osed 1st <br /> 300 ��9 I 1 System Elevation <br /> V 1.Tank Info Capacity to , Tonal s �� O <br /> Gallons Number Manufacturer Prefab Site , <br /> Gallons of Units Steel Fiber Plastic <br /> New Existing Concrete Constructed Glass <br /> ranks Tanks <br /> Septic ur HoldingTank GOD <br /> Acrubm Treatment Gut O �O Se.W `N•� <br /> Ousmp Chamber <br /> ill. Respo its,bilih'Statement- 1,the undersigned,assume responsibility for installation of the liTS shown an the at Inc hed plans. <br /> Plumber's Name IPnml <br /> Plumber's$ignaturc All'AIPR$Number <br /> R Ie le /7G �i n f !� - ! z p Business Phone Number <br /> Plumbers.Address( Ircet.City,Stant,Zip t-We) 7�S 9'66 <br /> 776 D /�w 3S Wc6sfev wr sy gg3 <br /> �'II osis De artment Use Onls <br /> Approved ❑ Disapproved Sanoary Pemmr Fee(includes Groundwater <br /> Surcharge Feel / Dare Issued Issu.ng A t azure tamps( <br /> ❑ Owner Given Reason for Denial <br /> 1\.Conditions of Approval/Reasons for Disapproval <br /> ApR 2 0 <br /> BURN l <br /> Auach couple(-pians ho Inc Counts only 1(or the(stem on paper not lass than 81:2 a I I incheslOn IVIsCoON� <br /> SBD-6398 (R. 01/03) <br />