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oec:atveae <br /> erl� Safety and Buildings Division CovenBurnett <br /> 0 o^ 201 W.Washington Ave.,P.O.Box 7162 Sanitary permit Number(in be filled in by CO) <br /> S <br /> pSi Madison,WI 53707-7162 <br /> 56- 6 <br /> vr'vMn�N <br /> Sanitary Permit Application Seen,T sieieo Number <br /> In ueuudame with SPS 3x321(2).We,Adm.Cods,submission of this form to the appeopose g^vermcntd unit PrgW Addeess(rdiRcrcm Nan mailingaddress) <br /> is requited pain to obtaining a sanimry permit. Nae:Application forms fur swrowned POtVTS art submitted b <br /> the IYp. in we of Safety and a privacy, <br /> Law, <br /> s.15. Persend Sees. dion yon pmvidc mry be used for swndary <br /> u ppl to tion Info with me Priv Law,s.t All 1 m,acts. <br /> LA Application Information-Yleau Print All Information <br /> Property Omrer's Name Parcel 4 <br /> Don Whitwell 07-0062-38-17-2&505-001-011000 <br /> Cod <br /> Hopedy(1voua*s Mailing Addreas ProPcnY l.natir n <br /> 23175 Carlson Rd. <br /> Govt.Ln 1 <br /> city State %ip Cade phone Nmnbe, Yti Semon 26 <br /> Siren WI 54872 715-222-9947 aisle one) <br /> II."fype of Building(check all that apply) I.np 'I'3R N; N17Gur V� <br /> B 1 or 2 Family Dwelling-Number of Monsoon 2 Subdivision Name <br /> Block a <br /> U Wblic Commereial-Ihsenbe Use <br /> ❑cnnr <br /> D Sam,Owned-Describe use CSM Number El Village of <br /> 19 Tavnof Daniels <br /> I11.'rype of Permit: (Chink only one box on line A. Complete line B if appliable) - - - - <br /> A, U Nev,Synrni ® RePlaamrnt System ❑'frcatmenVl folding Tank Ruplacaitou DnN U other muni iration to iftistg Syron(explain) <br /> B. U Permit R aux vid U Nunn Revision D CTtanige of plumber U=it'fremfx to New List Previous Permil Number and Dare Issued <br /> 6cf rc Expiration (Tums <br /> IV.Type of POWTS S stem/tenon nent/Device: Cheek sll that s 1 <br /> O Non-PrasurircA In-Gronnd U pressurircd In4imund U At-0nde U Momd>24 in,ofst itable soil D Mound<24 m.of suitable sail <br /> D l folding Tank D(Ther Dispersal Component(explain) ❑Prtueausnrt Device(explain) <br /> V.Dis eredfrrem cut Area Information: <br /> Design flow(6Pd) IXn,S Applicmiim Raud,pds0 [)isporsal Atea Requined(s0 Dispersal Area Pmpoox)(v Systom Elevation 1 <br /> 300 0.50 600 600 <br /> VI.Tank Into Capxitym 'Dual pof Menufacwrer <br /> Gallons Gallons nits <br /> PT—links Lxiving Tan4s `� c u tt <br /> 2 uU d <br /> senir,a°nm",:Tnn` 750 750 1 Wieser Concrete X <br /> oaungcTanba <br /> VIL Responsibility Statement- 1,thcundcrsigned,assume rceponubili for installation oldie pf)N' flvmarn on theanailud plans <br /> Plumho's Name(Pnm) plum Sign re MP/MpgS Number Basiatess Phone Number <br /> Robert Carlson 13%55 715653-2500 <br /> Plumber's Add.,(Sucel City,State,Zip Cele) /1 <br /> 3572115°St. Frederic WI 54837 <br /> VIII.County/Department Use Only <br /> D Approved D Dicatneved Permit Fc Doc Issued bauin IS..,. <br /> ❑(),mer Given Reason for Donial $ 3Z<5-"`V j <br /> IX.Conditions of A pprovallReasom for Disapproval D EC <br /> rENE <br /> AUG 5 2013 D <br /> amara maphtr way far tar mt.m and sab uk to our Caun y i nb••w,cr ean tar flue g.a a u ietlME1T COUNTY <br /> ZONING <br />