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Safety and Buildings Division CO" <br /> 201 W.Washington Aver,P.O.Boz 7162 � /p f fi <br /> �r'isconsin Madison,Wl 53707-7162 atY +=x' , <br /> ora Numbm�ttobefdkdisb ctmJ <br /> Depar�nt of Commerce _ (6(18)2663151 <br /> Sanitary Permit Application Stale Pbm I.D.Number <br /> In awmd widr Comm$3.21.Wit.A(Im.code. -� <br /> persoaai i ,S15.0 on you provide <br /> my be used for sc000dmy purposes Privaq taw,s15.(N(Ixm) Ropxt Address(if difluent done rtaitiag address) <br /> L Appliadim Information-Please Print All Information 'L U) <br /> Properly ownces Name PatQi t l.a♦ I —Black g <br /> 1)LIk Zp t'�71 o z s2)3 o�F2oo eta VOUA77 <br /> PropatY s Madog Adm pm�ty Location <br /> (0 b �' V, S C K inn <br /> eCStty.State Tip code panne Number �t <br /> IL type of BaGa®g(ehedc all that apply) <br /> 7/ -d y(e- 1 7 9�- T `FL N: R 1 S B ocW ) <br /> I or 2 Family Dwelling-Number of Bodmoma. 3 Subdivision Name cSM Number <br /> WMielCommadd-Describe Use <br /> Stw Owned-Describe Use city_ Vdtw } wa 5 V b 1 5 5 <br /> QL Typed Permit: (11m:k ody omeboot m Goa A. Complete tine B irapplicable) <br /> A. System Replacement SYS T . <br /> reameaYFoldrog Toot Replaoearart Only (Mier Modification a Bcistirtg Systaa <br /> B- Permit Renewal Permit Revision Cluage of Purait Transfer to Nt Previous Plow Ciss Penm <br /> at Number std Due Issd <br /> Before Bspuatimr Plumber Owner <br /> Iv.Type of POVM s akwk an that 1 ---- <br /> Non--Pammaod Mound2:24 in.ofsuWAk sal Mound<2fi.a,of suimbic set At-Cmade Single Pass Sand Filter <br /> Com khtood Wetand Piaswri d armwW Howmg Toot Peat RWcr Ambit Treatment Unit Roacu idmg Sam!Filter <br /> I Recirailating Symbenc Media Fditc Leaching Chamber Drip Lim Gmvd-kat pipe 01her(sapain) <br /> V.Dbpessalfrimbuest Area foformatim: —� <br /> Design flow(gpd) Design Sal AppRcatoa Rate(gp%o Dispersal Ates Required(an Otspemi Aux Purposed(sl) System Ek"two <br /> LI <br /> VL Tank Info Capacity in Taal Number Maaaaclmer hefsb Site Sled Fibs Plastic <br /> Gallons Galons of Units Concrese Construcled Gime <br /> Now FAM"s <br /> Tadu Taub <br /> Septic or Hutting Tat K l WQtSPr C�Ncr-�e7e. <br /> Aerobic Tseammt Unit <br /> DmYg l>kamber <br /> _VII.ResponsibUily Statement-I,th assume for IashBatiw of We POWTS ahaao m the antteLsd <br /> plumber's Name(Prot) Plmubeex skpam c MPIMPRS Natebcr Busbrea Phom Number <br /> 4 <br /> Plumbees Address(Staet,City.State.Tip Code) <br /> (?sT MOJ�-Ciu?- 5T-- cKotY, (-tL& W= SL( OXL/ <br /> VIIL use Oat <br /> V Appu"d DaWro`ed s � Fe (includes <br /> Vem=WwweDate Lumdyl, NStan")i <br /> Owmsr Given Reason for Denial <br /> s� •36l' <br /> 6 r vy <br /> RC.CmAtions of Appro"WReasoos for Disapproval <br />