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Safety and Bmlditgs D"msior Couay <br /> 201 W.Washingson Ave.,P.O.Box 7162 �r AVO <br /> Awonsin Mtldison,WI 53707—7162 Sanitary PumitNlmlba(to be filled in by Co.) <br /> (609)266-3151 . I,r7/�i f 2 <br /> Department of Commerce '"'( `t' <br /> Sanitary Permit Application sty Plan I.D.Naber <br /> In accord with Comm 6331,Wer.Adm.Code,personal infamaim you provide C5 <br /> am be and far secondary Purposes Privacy taw,315.04(I)(m) - Project Address(ifdiD'eraa than n dli gaddres) qj <br /> 1. Application Information-Pit=Print All Deformation <br /> ]haperty OmrraName Prado I.o/o Blodro <br /> Nx-401as Y--(Tv/.e plan O O/Z - Vzo/66 -/00 <br /> Property Owner's Mailing Add.® Property r1L0 <br /> Z fT3 )eq�a/e �r'Vco Go v'i God / <br /> City.Stag Zip Code Phom Nmba ik K, Section <br /> T_N; R <br /> oV.,d trew /* <br /> r3Sirz 1�3- - 0 ya &TaW <br /> H.Type of Brldiag(cheek as that appy) p <br /> 101 or2 Fmiy mrm Dwelling ofBed ,.J Subdivision Name CSM Numbr <br /> ❑PuldnACmmre tial-Describe Use <br /> 11 State Owned-D=nbe Uses ❑City ❑Vdlage*ownship of --T�JrfSW <br /> III.Type of Permit (Check onlyore boz oa Bre A. Complete Bre B)f■ppgrable) <br /> A. ❑New System �Iteplmsnad Systerrr ❑TrprnanVHolding Tank Replsmnenl Only 0O6nrr Modifiotann to Fainting Syron <br /> B• ❑Peanit Ramwai ❑Permit Revision ❑crap of ❑Permit Transfer ftoNew lid Previo s Permit Naber and Date land <br /> Before Expiation Plumber Owner <br /> IV-Type ofPOWT3Systems: Cberkall that apply) <br /> ,.Non-Pr=unzed krGrmmd ❑Mou d>24 m.cd7. dAc soil ❑Mond<24 un.of suit"amt ❑AKaade ❑Single Pecs gad Filler ❑ <br /> ConshmZed Weds d ❑Pamr=d ln-sou rd ❑Holding Tank ❑Pmt FPhc ❑Aerobic Tmelnaa Unit ❑Recw dw'g Su d Finer ❑ <br /> Reciradatirg 8rdmuc Modic Fella ❑laaLing Climber ❑Drip tine ❑Gravel-les Pipe ❑0dar(eaplain) <br /> V.Disperwaliffreatment Area Information: <br /> Design Flaw(bpd) Design Soil App iatao Rates) Diapasel Arra Req=W(s0 Dwpaml Arra Proposed Of) Systm Elevdton� TS <br /> YT6 1 16/ 1 1 1. 1 'IYlp• y 7/ 96 • tz7,r93P3- <br /> VI.Tank Info Capacity in Tote) Number Manuilw aer Prefab site <br /> Glens <br /> Stool Fba plastic <br /> Gallery Gallons ofUdts Concrete Coaaucl d <br /> New F dWft <br /> Taub Lair <br /> SqA wHoMmgLdr `ese"(' X <br /> Aacbic Tromes Ung <br /> Dwtag(.Bamber <br /> VII.Responsibility 3fatemeet->,the ud,rwped,aaame dtltlq Por imfaBsWer of the POVM sbo m oa the athehrd peas. <br /> Plumb <br /> a Name Poon a S" MVMPRS Nmba Busman Phone Number <br /> Pomn ner•s,Address(Soak City,Slate,Zip Code) <br /> 3.�%z /is� s'�' . edea-� r✓v• ' � �� <br /> VIP.ConatLAgLenronstatt Use Only <br /> W�Apprvvcd El Disapproved SH <br /> wy l}mit I=(orJules Groundwaternote lard igmtre ) <br /> Sucinup Fee) '1 <br /> ❑Owner Given Reason for Daniel Ci(+ Jt� g' e-5 <br /> UL Conditions of ApprovaURaeons for Disapproval <br /> Aura eawpkae plea(a 1ieCamaly sty)fr mesras v RQarta it gl/l:11 Drier i a� <br /> SBD-6398 (R. 01/03) <br />