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commerce wl.pov Safety and Buildings Division CountyI7 <br /> 201 W.Washington Ave.,P.O.Box 7162 U 1"r n <br /> ' CDSPWbOnC n Madison,W153707-7162 Sanitary Peng Number(to be fined in by Co.) <br /> at &30.193 <br /> �Sanitary Permit Application ""'T'an°'a'°"Number <br /> In aamrdmm with e.Conor.113.21(2L Wis.Ado.Code,whmmiae of Pois faun to the%Tmptiase goveaommhl CoA-- /CUI Gk7 <br /> � requited prior to obtaining a uoiMY Iwmit Note: Application fauns for aMeowoed POW TS am Project Address ka of nc est than mailing adders) V I <br /> to the Department of Conmace. Personal iafomution you Provide may he used for secondary <br /> in accordance with tr Priv Law S.15. 1 n Stalk. 3 ()7S-6 <br /> L A tion infarmatim-Please Print An hafwmatlon '1U H S L n <br /> Property Owner's Nene <br /> /j. Parcel# <br /> 57"Ew4f De. -I �eh.niJ dt^ 4�J4a,. 5 dad. ,-Sd/9 � OS'DOp <br /> Pmpaly Owns's MailingAddratit <br /> Propmty Location <br /> / 73 .0 P/v q e r,. L. h GavL La / <br /> Com'stare / 2iP Cnm Phone Number 'b, SL, Section <br /> r<✓ L, le N-) 7V (eieleone) <br /> IL Type es Bhdding;(lawk all that apply) Lot# T 4/ N; R_S-EsW <br /> ®1 or 2 Family Dwelling-Nembs of Bedrooms 13 Subdivision Name <br /> Block# <br /> ❑Publidm <br /> Comscial-Daeribe Use <br /> ❑City of <br /> ❑State Owned-Danibe Use CSMNamber ❑Village of <br /> R Town of tea+ tf,S <br /> III.Type of Permit- ((hul <br /> gpk Orly me box m line A. Campilege rate B hi awrA.W)n _d3 _ _ – <br /> A. ❑New Systems Pt Replaomant System ❑Trmtmnt/HoTask <br /> r J <br /> Wing Tank Replaermcat Only ❑Other Modification to F,xutmg System(mepbm) <br /> B- ❑ps,milRmewal ❑Pamir Revuin ❑chmgaofPhmMr ❑pent Transfsto New Lot Previous pkmha Nanbsaud Date lured <br /> Before Expiration Owns 05 0 <br /> IV.Type of POWTS Cam t/Devica Check an strut apply) C . <br /> r❑N.Pmsurized In-Ground ❑pressurizedInGrormd ❑AK'mde ❑Mound 24 m.of suitable axil ❑Mnnd<24 m.of suitable sod <br /> r� <br /> ys HAWS Trek ❑qhs Dup.A t(.PIs®) ❑Aeir b d Dev ce <br /> (exPl+o) <br /> V.Dispersavrrvatinew Area inforseadow <br /> Design Flow(gpd) Design Soil Application Rate( xid) Diep ZW Am Raqui ed(a!) Dapaval Am proposed(st) Systm Elevation <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> GaOnm Gallons Units n <br /> New Tama �Tmd- <br /> Sephcallddmg Trek �-b3 a /GGG — �i S 5��4 <br /> Da ngChmbor <br /> VII- Statemmt-1,the anderai ed,anise responsibility for)astatatioa of the POWTS Iowa as the attaebed Igans. <br /> Plamba's Nave al int') Plombs'a Signsme A8/MPRS Number Business phone Number <br /> ��1Glc ,70 <br /> Monsber's Addmm(Sime[,City,State,Zip Code) <br /> 35- weSs �' r� W,, .5-4593 <br /> VI am artment useOub <br /> Awnwad ❑DuaWaved I PermitFa Dan AAIs-s"ued LOW" <br /> ❑Owns Gives Resin for Damm s 375 17,�i/lbke 01 , <br /> DL Cnd dung of ApprovaVReasoro for Dhapprwval <br /> 't>Ep�AeEs T A1L. 2wO 54/16n 444'-;l 714/ In-<64V ie, 1963. <br /> Attheh Y erhhpho phrhrthe syohns and smmYYthe Csuntyunyr papr rt kmtbrt to a II laekm fa run <br /> SBD-6399(R.02109)Valid thio 02/11 <br />