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Sala.,and Building; Dniomio Cnnu. <br /> F 'U 11 -------------- <br /> 1'. R'ashm�ton A%e. P.0 Bot 'I D: <br /> ISO <br /> NN isconsin - �`�� �'` <br /> I��J�KUII. ��I J I'll' �I D� Sijaiuiary Penna Nuniher 1111 be IiIIca in b'.Co 1 <br /> Department of Commerce (t)(18I Jon-3131 5L5c n 7 <br /> Sanitary Permit Application Stale Plan IIDNwnbcr M <br /> In accord with Comm gl_'I.%%is. %Jut.Code.puxmal mhmnanun you firm do /00-5007 <br /> may be used far xcnndary purpoics Pritacy Law.sl i dal 1'Joll / t <br /> Proyeu Adders nl'Jiifcrcm rtun niaJmg aJJressl W <br /> I. :application Information-Please Print.All Information (y 2 <br /> Property Owners Name • [/-J /Dep <br /> Parcel a Lot a Black a <br /> S�e�e M1/rte OJ�v -LE335'- 03 X06 <br /> Propcny Owncr's%failing Address <br /> /0• bd0 <br /> Property Location Gov` <br /> (�evBr^ Lir • '' <br /> ley.$ram ZIP Code Phone Number •. Seaton 39 <br /> �y <br /> ? /e f/a/Ie ✓CS/�t y �$-.1-3az�. -3030 !Iarc�lc o ) <br /> I40 I.Type of Building(check all that appl ) T_N. R 6 E A <br /> I or'-Family Dwelling-Number of Bedroom; 3 Subdnt>wn Nt <br /> CSNI Number <br /> ❑ Public Commercial-Describe Use C -7 3 <br /> ❑Stam Owned-Describe Use ❑City_❑Vdlhip of 013k/4t+ <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> Jew System ❑ Replacement System ❑ Treatnent Holding Tank Replacement Only ❑Other Aludi isting System <br /> B. ❑ Permit Renewal ❑ Permit Rn awn ❑Chan ie of List Previous Permit Number and Date Issued <br /> Before Espoatrom ❑Prnnu Transfer w New <br /> Plumber Owner <br /> W.Tc pc of PO%%TS Ssstem: Check all that a Ivl <br /> .❑Non-Pressurized In-Ground ❑ Mound>]a in.of suitable soil Mound<24m of suitable soil ❑ At-Grade <br /> ❑ Single Pass Sand Filter U <br /> Constructed Roland Cl Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Fiher ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Grateldess Pipe p C1 Other(explain) <br /> V. Dis crsal/Treatment.Area Information: <br /> Design Flow(gpdI Design Sod Application Ratelgpilst) Dispersal Area Required Iso Dispersal Area Proposed Ist) System Elevation <br /> qrO /. 0 -SO y :s0 y C17. g r <br /> %T.Tank Info Capacity in Total Number <br /> Alanufacwrer Prefab Site Steel Fiber <br /> Gallons Gallons of Units Concrete Constructed <br /> New Existing Glass Plastic <br /> Tank$ Tanks <br /> Scpnc ur HuWmg rank <br /> /000 <br /> Acrubiu Treatment Unit <br /> Dosing Chamber i <br /> bn�t_ <br /> DODO X00 <br /> %11.Responsibility$tatemen[- I,the undersigned,assume responsibility for installation of the PO%%TS shown an the attached plans. <br /> Plumbers Name(Pit nil Plumber's Signature All'AIPRS Number <br /> Business Phone Number <br /> Plumber's Address(Street.Gry.State.Zip Code) <br /> 04 '760 �t✓ s�.S' utIebs71'e� f t/1 serf PF <br /> 1.County apartment Use Only <br /> Approved ❑ Disapproved Sanitary Penne Fee Iincludes Groundwater Date Issued Issu.n Signa (No Stamps) <br /> Surcharge Feel a ,3000 AV_�� <br /> ❑Owner Craven Reason for Denial 4P <br /> IN.Conditions of Approval/Reasons for Disapproval <br /> Ca PL_ <br /> JUN _ 7 �4 i <br /> BURNS <br /> Atach complete plans fro the Counit only I fur Ilio ysrrm nn paper not less IAanryr /yyin t <br /> SBD-6398 (R. 01/03) <br />