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Safety and Buildings Division CouNAddmss <br /> JD. <br /> 201 W.Washington Ave.,P.O.Box 7162 e <br /> tmSconsin Madison,WI 53 707-7162 Smber(mbcBlleinbvCoI <br /> of Commeroe (608)266-3151 (00 <br /> Sanitary Permit Application Stater <br /> In accord with Comin 83 21,We Adm.Code,personal information you provide T7- <br /> maybemePorsecondary purposes Privacy Col.315.04(I)(m) Projffeurt Nun mailing address) <br /> 1. Application information-Pleam Print All Information <br /> 3 a� 7GH6 Ga Puml'< Ur. <br /> Property Owners Name <br /> Parcel# Lotp ? Blocks <br /> Sraeve Wit! ('e ado 9/7/ <br /> 0, is Mor ya0 <br /> Ropetty O 's ailing Address Property L.anon <br /> 434 <br /> City,Stat, Zip Cade Phone Number —/S —I+ Section 10 <br /> INA A'-VM MNSS/rs dth 47o-6�L (clmlacnc) <br /> 11.Type of Bailding(check all[hat apply) p T_40 N; R_Z Eo® <br /> A I or 2 Family Dual-Number ofBemoms J Subdivision Name CSM/Number �I <br /> 12Public/Cummemial-Describe Use W ( /-,V_ <br /> ❑slate Owned-Deseribe Use ❑city_❑vdinge B!Tgwnship of Oel/14.'o �TC� <br /> Ell.'rype of Permit: (Check only one box on if. A. Complete line B ifapplicable) <br /> A. y,New System ❑Replacement5 rem <br /> ys ❑TlnlmcnUllolding Tank Replawmenl Only ❑Mer Modification to Existing Sys[cm <br /> FU ❑11mul Renewal ❑Permit Revision ❑Change of ❑Pemrit Transfer to NevLia Previous Permit Number and Date bsue <br /> Befom Expiration Plumber Owner <br /> 1 <br /> IVy <br /> a .T cof POWTSS stem: Check all that¢ <br /> Jm Nnn—PressmizW In. mxl ❑Mouon>24 in.namable soil ❑Mound a 24 in.of suitable soil ❑As-Grade ❑Single Pass Send Filter ❑ <br /> Constructed Wetland ❑Fressurined hn- oand ❑Holding Tank ❑Peat Filler ❑Aerobic Treatmenl Unit ❑Returning,Sand Filter ❑ <br /> RecovolatingSnthetic Meia Filter ❑Leaching Chamber ❑Drip Line 110covel-lemPIRE LIONer(explain) <br /> V.Bis ersaVrreatal Area lnformafion: <br /> D elm Flow(gpd) Design Soil Ap: Its ion Rate(gpds0 Dispersal Area Required(sfl Dispersal A¢a Encircled(10 System Elevation <br /> 4-f0 '7 6HJ C.ner 73.0 94. 0 <br /> VL Tank Info Capacityin Total Number Manufacturer prefah Site ten Fiber plastic <br /> (74,ill.. Didion. of Una, Concrete Connected Glass <br /> Nsw Eaikny <br /> N n <br /> TnnW <br /> ActacarlbiniesTa, /000 <br /> Aerobic Tngnem unit /000 w.. X <br /> Doses Chamber <br /> VII.Responsibility Statement-4 me undenigpetl,aanume rnppnsibilily fur imtallafwn of IM1s POWTS shown an IM1e etlecM1e pinna <br /> Plumber's Name(Print) Plumber's Signature MP/MPRs Number Business Phone Number <br /> rQrek ye ,E,,,J /2se,4..aQ .Y /{kgs/ Ira= �4s- vs7 <br /> Plumbers Address(Street.City,Stare.Zip Cone) <br /> 7760 H r 3r websl'er wr Syg9J <br /> Va .Count /De artment Use cm. <br /> Approve ❑Disapproved Sanitary Pnmit Ftt(inludca Grqurdwater Ugate lsspued Issu g Reason Orem Sigw oStamps) <br /> Surcharge Fee) y�.JjCL/t / �L AI <br /> ❑ wner en rnr venial Jl <br /> IX.Conditions of ApprovaVReuons for Diwtpproval <br /> A+MM1 campnn pbm(m Ike County anb)Iw IM1e+Yenm m Aper nml®+IWn e1R x II InsM1n In+is <br /> SBD-6398 (R. 01/03) <br />