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Count <br /> (woc <br /> ^^ '�'. Safety and Buildings Division ,(Jap . _ <br /> S" 1400 E Washington Ave Sanitary Peearniittt Number(to be filled in by Co) <br /> ' '�� F.D. Box 7162 JW/-IS�y <br /> 'S Madison,WI 53707-7162 I <br /> Sanitary Permit Application State Tmmaaion Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this born to Nc appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POW­[S arc submitted in Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br /> p.,.s in accordance with the Privac I.,s. 15.04 I m Stats. sat <br /> 1. Application Information-Please Print All Information Yr <br /> Property Ownpr's a Parcel 137 Dab <br /> 27 �c/1�73.�-� S d OSG Doo <br /> Property Owner's Mail ing Address Property Location <br /> a896,1 <br /> City,State / Zip Code Phone Nu/mber Govt.Lot_ <br /> W b U/' W->L sy �6 3�z�' ale <br /> 11.Type of Building(check all that apply) Lot M K, Section <br /> TN; k <br /> Art Family Dwelling-Number ofUciromm C2 _ Y" Subdivision Nam. <br /> _ // r <br /> ,�- BlockN PArrl"4.5 �✓L^✓' X7-3-e_;5 <br /> 11 Public/Commcrcial-Ilescribe llsc <br /> / — Cl City of <br /> ❑State Owned-Dcaeribe Use C� CSM Number El Village of f, <br /> At own of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System epforament System DTlestmc.01.1ding Took Rcplacemcat Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Rencwai ❑ Permit Revision ❑Change aFP]umber ❑Peamit'Dowler to New List Previous Permit Number mrd Bak Issued <br /> Before Extinction Owner <br /> IV.Type of PO\YTS S stem/Com onent/Device: ICheck all that a I <br /> on-Presocired l.-Ground ❑Pressurized In-Ground 11 Al-Guide ❑ Mound>_24 in.ofsuitablc,.ii ❑Mound 124 in,ofsuitable .it <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treolment Area Information: <br /> Design]:low(gpd) Design Soil Application Ratc(gpNO Dispersal Ama RcquirW(s0 Dispersal Area Proposed IsQ System Elevatio <br /> VI.Tank Info Capacity in l'otal 'a of Manufacturer _ g <br /> Gallons Gallon Gnits a u d c <br /> Newl'enka Cutiug'renks <br /> since or Imo?=1k- <br /> Deve,cnamAr <br /> VII.Responsibility Statement- 1,the undersigned,assns¢respunsthiliry fur Installation of the POWIS shown on the attached plans. <br /> Plumber's Name(Ph Plumber's Signature MP/MI'RS Number Business Plane Number <br /> WADE RUFSHOI.M / yt� 227691 715-349-7286 <br /> Plumber's Address(Street.City,State,Zip Code) LeGC¢i <br /> PO BOX 514,SIREN,W 1 54872 <br /> j VIII.Count /De actuator Use OnI <br /> Approved El Disapproved Permit Fac Dae Issued Issuing Age I Sigma.. <br /> s 7iZSva g_8'/H 1 ir„fie s� <br /> ❑Oxnv Given Rruson bar Ucnial `I <br /> IX.Conditions afApprovaVRcasons for Disapproval 1I L1 �Lr) �-�L <br /> u AUG - 7 2014 U <br /> -r Ir n_/_r nrmcnmmmnlete nlero roahegsatm sne submit mrne Cnuntr Dolt an nvtur notlm tMna dna <br /> "I tVD ZONING <br />