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eommeree.wl.gov Safely and Buildings Division County --- <br /> 201 W.Washington Aac.. 110. Ilos 7162 <br /> isconsin Madison. Wl 53707 7162 SanilaryPermit Number(Io6efillcdinbyCoJ <br /> DepnrtmeM of Commerce <br /> Sanitary Permit Application nN 9(0 ---- <br /> SWIc'1'ransaclion Number <br /> In accordasmc with s.Comm.83.21(2),Wis.Adm.Cod.,submission ol'thir to do,splaopriaze g.,omoa.'ntal �� <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms far slate-osvnal p()W'fS <br /> are n� <br /> submitted to the Department of Commerce. Personal information 1 Project Address(if different[ban mailing addreaej W <br /> SO in Seounlanee with the PrivacyLaw,a.15.04(1)(m),Stats }ou provide may be used for secondary / pp <br /> I. A Iic t"an lnforntatlon—please Print All Information 2,3294;4 /'K6NLN f.Of�� <br /> Property Owner's Name C� <br /> Irarcel q <br /> Properly(honer a Mailing Address "`-�v I Oa C> 2 if) O/:5-0(5 <br /> Property Location <br /> �Il) C_ <br /> ny,h ale Zip Code Phone Number GNoLot <br /> /VV ,• AJ c .. Section rcle one)) <br /> 11.Type of Ruildi (check Sell that apply) ------ 'f— <br /> �¢_N: R /t/le, P:o(V <br /> Pity) 3 Laln <br /> ❑ 1 or 217amily Dwelling-Number 01-Bedrooms — Subdivision Name <br /> -� Blnck l' — — <br /> Irubli./Commcrcial Describe Clsc <br /> ❑ City of <br /> ❑Slalc Owned -Describe Use -. _. CSM Nmnbcr ❑ vil)ag.of �— - - <br /> Y'r'own of <br /> 111.'Type of Permit: (Check only one box on line A. Complete line 13 if applicahle) <br /> JA, <br /> w System ; (R-placemcnl System ❑ 'frcahnent/Ilolding'fank Replacement only ❑ Other Modil ealinn to)xisling System(caplam) <br /> mit Renewal ❑ Permit Revivinn ❑ Chan a of Plumber List Previous Permit Number and Date Isonal <br /> F ❑Pcrmil'1mnsfcrto Ncw nExpiration Owner a 0 I br, <br /> IV.Tv a of POWTS Sstem/Com ment(Deviee: Check all that a Iv) IV,J -- <br /> on-PressurvcJ In-Ground ❑ Pressurized In-Ground ❑ AI-(;rade <br /> ❑ fs4runJ_24 in.of sellable ,,it El Mound<24 in.of suiWbk sail <br /> ❑ Iloading Tank ❑Other Dispen;al Component(explain)_ _ _ ❑Preiremmenl Device(explain) <br /> V.Dis crsal/frcalntent Arca htfonnafiun: ---._ <br /> Ucaign Plow(gpd) Design Soil Application Rale(glxlaQ Dispclsal Mc cq nied(sQ Dispersal Arca Proposed(sQ Sys0.•m Plevalion <br /> n 6 iso ,ze 50 <br /> Vl.Tank Info Capacity in 'Total H of Manulactun:r <br /> Gallons Gallons Unils u c <br /> New Tanks Existing Tank. , V <br /> `v eo g 15 G y <br /> Septic a Ila4lipy lade— t� U %n 3 <br /> —an <br /> DOb 004 <br /> Dosing Clwm Mr <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation(if the POWTS shown on the attached plans. <br /> Plumbers Name(Prin1l Plumber's Signature MPRvIPRS Number Business Phone Number <br /> t3 a//ry z")orl-- 2 z7G 9/ <br /> Plumber's Address(SlreeL Cil.,Stale,%ip Codc) <br /> �o S-/ y s���IJ Se/87.2 <br /> Vitt County/Department Use Only <br /> Approved ❑ D'aappmved Pe'mit I'e; lUh�aftl].�hsxucd /� Issuing.4g alure --_ <br /> ❑ Owner Given Reason for Denial s �✓D� 4x�-,2Ir wtr <br /> IX.Conditions of Approval/Reasons for Disapproval - <br /> Fbr6: Bpeu(,s Fr,,, Eha (Xf9MIsl Sud 6v�e�kr 0.+D SINK- goo <br /> Ders,(��e � Aft drn re <br /> I� SwtAA�6 sore Aeta�✓7,bu C6[.L ,�6,1. <br /> Attach m mmplele plam for the rystem and su Wnit to the County only on Paper not tem than s in a 11 Inches th sloe <br /> SBD-6398(R.01/07)Valid thro 01/09 <br />