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-_.__-_. <br /> commerce.wl.gov - Salcty and Buildinp nlvisn)n I -i.um,ly <br /> 201 W Washington Ave.,P.O. Box 71(12 <br /> tDoplartment isoonsin Mmllson,W1 53707 71h). Samta Permit Number(lo be filled m by <br /> of Commerce <br /> Sanitary Permit Application Some Transaction Number <br /> fn accordance with s.Comm.83.21(2),Wis.Adm.Code,submission ol'this form to the appropri is governmental <br /> unit is required prior to obtaining a sanitary permit. Note. Application forms for slneowncd POOPS me Project Address(il'Ail'Icrentthan lrwding address) <br /> submitted to the Dcparm,ent of Commerce. Personal intorn aims you provide nary . used for Scc(nd91'y ;23 2 7 .Z <br /> -T- <br /> purposes oses til accordance with the Privacy Law,s. I SnQ I (Ill,StatF, , ` <br /> 1. Application Information-Please Print All Information <br /> Property Owner's <br /> wner'\�Na nc <br /> ]ZIP <br /> - — <br /> _ _parcel t <br /> ProIxrl <br /> lo_ <br /> c_a_t_io-nMailing Address� Q_7_ L (luvl Lot <br /> City, Code Phone Nunthen N(/ / IUc-. <br /> Section <br /> ection <br /> ;z/- <br /> circle title) <br /> 6-2/9 3 <br /> lcircletitle)5y/P3 <br /> 11. I;Vpe of Building(check all that apply) Lm Il <br /> — S:wdrvlslon Neulc <br /> ❑ I or 2 Funily Dwelling Number of hcdraons -_ _ - <br /> Block l! - - -- —' <br /> ` 'uhlic/(bnuncmialDcscrihc Use _ (+'.Qj F1 city of <br /> t CSM Nwnhcr ❑ Village of <br /> E)State Owned Describe Use _-_ _ - _. <br /> t*"Iown of <br /> -. <br /> III Type of 1 tl mals (Check only one box on line A complete hot t;If applicable) _ <br /> A ❑ New Systenn �Replacenanl System O I rc on,,o,,lloldaog lank Rcpla etncnt(1 dy ❑ odic,Modification to Existing System(exldainl <br /> List I avunns[lei on Number and Dntc hared <br /> I strait ttnncwal ❑ Pcmut Rcvmuml � ❑ (h mile ll I lumbo I F)PcIInn I I auto to N,-w <br /> L=10re Ie I xpunlon Uw w <br /> 111 .I'-_. ------.'-_- <br /> �IIV. )'ype of IOW PS System/CumL nentlDcvicc: (Check all that apply) <br /> y� Non-Pressurucd lo-Ground ❑ Pressunecol In-Ground rI At-(node ❑ Momul 24 inof sl itahla roil n Mound<241n of vmtaldu., II <br /> Ocso ding lank [J Other Dl nal(ora c nc n(explain) Ll Prcta ran tot Dcvu.c(cxphI1d <br /> -- — - - <br /> persal/I rcatmeut Area information: - _ . -- --- <br /> Design low(l pd) Dsign Sad sp Ulspclx 1 <br /> eAppliceuon R nc(ypd ` 1 Area Ree iio.d 1+11 U p r d A 1 I Imposed( tun I levuuon <br /> �1 <br /> , 7 I sys � 7 0 sQ Sy\ <br /> ._ 0 9S, 8' <br /> Vl.Tank 111(11total Il of Manld,tchlat v c v <br /> Gallon, Gallons thin, °.° o U y 'C <br /> - <br /> o. <br /> __ -- Plunthu s Sn na¢uc.. —Y--._ - _ 15 sbnwn On the attached plans. <br /> Plu"thur',Nnnu(Pin 1) m g mmivi I2S Number Bosatw.1 phone Number <br /> V11. <br /> ll EIAs ons flit Statement- <br /> /lyalcme mdcn ulnc responsibility for mslallalinn al the 1'UW �Z.7 �� <br /> Ilunlbcr's Addax(Strcct,(ny Stne,l.Ip("dc) V <br /> VIII 'crmrt/ County/UQ.vtmenl Use 011ly •naltlee - <br /> , - If cc Date hied Isvmng ant <br /> LiI Approved I Ll is, _ _.I '6 3 V H/Z/ivp.. <br /> L[I Owner Given Reason for Detual Il �/(J t/U.. -- --_ ----- <br /> IX.Conditions of Approval/licasons for Disapproval <br /> --" - —- - - '\Illi'lila\11111 1 11,Itll t 1111 11 I)1111 Il.lp\1 II111 Il tt Ih.11 a Ill Y tl IIICIILf'1.1\1%l' <br /> 111 II III Clll 1polll plait,rill'It ) <br /> s HD-6399(It.01/07)Valid till"01/09 <br />