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6Q <br /> commerce.wl.gov S. Washington <br /> er and BuildingsDivisionO. County <br /> 201 W Wa}hm iter Ave.,Avc P.O.P O.Box 7162 <br /> iseonsin Madison,Wl 53707 7162 Sanitary Permit Nlmlberpobc tilled in by <br /> Department of Commoroo 2 <br /> LL135-- 0j <br /> Sanitary Permit Application Slate Transaction Ntamhcr ( �') <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission or this faun to the appropriate govcrinncnurl <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms ]or state-owned POW'I'S oro Project Address(iftiffemnt than mailing address) �S[ <br /> submitted to the Department of Commerce. Personal infunmition you provide may be uxd lar secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 I m),Stals. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Pat cc]N <br /> 06 4- O:y <br /> Property Owner's Mailing Address Property Location /1 C-/ <br /> �_ Govl Lot-- <br /> — -- _ /a2 <br /> Crty,State 'Lip C o(k I'honc Nunther �t'-, / / SSection_.._, <br /> a� d 6 y83 d f zeta one <br /> If I ype of Iluildi g(check all that apply) Lot <br /> ❑ 1 or 2 Family Dwelling -Number of Bedrooms _ _ Soadivtaon Name <br /> Block N � <br /> ❑Public/Conunerciai -Describe Use _. ❑ Cityol'- .__ <br /> CSM Wmdrer El village of__ <br /> El State OwnedDescribe Use _._. ....._ _.._.-_ � r <br /> f�lbwn of__L�.anll-O i4/._ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A <br /> ❑New System 19 Replacement System ❑lrcatmcni/I Inlding'rank Replacement Only ❑Other Modification to Existing System(explain) <br /> -- - _-- --- - -List Previous Permit Nwnbcrvu d D rte Isuicd <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑c tan fc of Plumber ❑I(nun I:utile. to N w <br /> Before Expiration Own <br /> V.Tyre of POW_I'S SSStem/Compmunt/Device_ � l <br /> .- tccl(all than apply) <br /> Xwnn-Pressurized In-Ground ❑ Pressurized hi-Ground ❑ AP(oadc (.( Mound �24 in. ,I citable,,it ❑ Mound 124 in.ofsuitahlc sail <br /> ❑ Bolding lank ❑Other Dispersal C'ompuncnt(explain)_- _.... -- �.)I'tclrc:amcnt Device(explain)_.. <br /> V. Dispersal/Treatment Area Information: <br /> -- <br /> Design Flow Ignd) Design Soil Application Rate(gpds) IT persal Arc t Req,wed l+q Dnpu til At .a I'rolwsal(s) System rlevJuat <br /> ----- --- <br /> VL'1'ank Info Capacity in I'uhd II of Mannl:Icuncr <br /> Gallons Gallons Unita 8 V y .� <br /> New Tanks 1`nining Tank,e o E <br /> —. <br /> on"),lloldine'I auk OOD �� wd �}�'(�✓ — <br /> Dosmg 01am8er <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POW I'S shown an the attached phos. _ <br /> Plumber's Name(Prins) Plu�rIMI'/Ml'R8 Number Business Phone Number <br /> Plumber's Address(Street,City,Stale,Zip Code) <br /> .5_j i's <br /> V 11.CnlDeynsvt ens Use <br /> untyOnly <br /> I I enol lies Dnc Issued Isuun gent Signature a <br /> Apro <br /> pved ❑ Disapproved y 10—j9—C9❑Owner Given Reason for Denial rCD -- <br /> IX.Conditions of Approval/lteasons for Disapproval <br /> ____._.—_-----__._ ..-. <br /> Allaeh In wmplate Plans fur the s) I•m and vihiml In the Uw iry orb nn paP✓not Icsz Than N IIx z I I inches in z(m <br /> SDD-6198(It.01/07)Valid lbru 01/09 <br />