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g . - <br /> rce.wi.gov 201 W. Wahim ton A e., Ury cion County <br /> Safct andLirlldvc.,P O Box 7162tiscocmmc' <br /> � Madison,WI 537077162 Sanitary Permit Nunibcr(rohe tilled Tr by Co_) <br /> Department of Commorce S r Q <br /> -__ <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with s.Comm.83 21(2),Wis.Adm Code,submission of this form to the appropriate govcuuncntal <br /> unit is required prior to obtaining a sanitary permit. Note Application forms for state-owned POW'I S are Project Andress(if different than malting addressl <br /> submitted to the Department of Commerce. Personal Information you providemay be used for ee oadary <br /> p Y <br /> ur osos in accordance with the PrivacyLaws s_ I5 04(I)(m) Stals _ -3(,� �.Q g-, '5 e ��/,Cf <br /> I. Appl <br /> ication Information Please Print AI /� �Information� -- / '-- -r (i Locatiol��-5' cle/ 7 0 a <br /> Propert Owner s Name /l// I Property --- <br /> Property Owner s Maili g Address <br /> /'a By �Y � / 7 5`G Code _ Govi.LotPhone <br /> --_p- p-- -. <br /> Zip <br /> City, -- NI Y) r s� [7 Number 69O -601 —r6 y �s N R Section <br /> w� <br /> Y, <br /> an <br /> n W <br /> 11 Cyp'of Bolden cheek all that a rl _ _ <br /> i Idivi Iun Nam <br /> LKI o[2Pnmily Dwelling-Numbcrof Bedrooms __ _ _. '37 <br /> Block N y/ e-P— r o,� <br /> ❑Public/Commcmaal Dcscdbc Lsc—. - —__ -- City of,_ <br /> CSM Number, � 0 Village of - <br /> ❑Store Owned Dcscnbc Cee __ _ _ - Q� <br /> ^ d own of <br /> ❑L'Cype of Permit: (Check only tine box on line A Complete tine R if applicable) - <br /> A <br /> New System Replacement Systcm I rcabnent/f lalding'fank Repinccmnent Only 11 Oder Modification to Existing System(cxplam i/ <br /> _ List 1 rcvioue Pcrntn Nnmbcr Itnd Uatc Ixucd <br /> 14. Olorerl!x Riralimal ❑ Femur Rr. roion )� ChanP,col Plumbu ❑Peruulrnsfa to 14" <br /> p �Ow <br /> —_ <br /> — --- <br /> Iv Tye of POW1'S System_I_C ompone,nUT)ev[ce: (Check all that apply) - <br /> [] <br /> Non-Pressurized In-Ground ❑ Preserved In-Ground [I At tirade ❑ Mound 24 Inof suuahlc ,,it f] Mound 24 mr of suitable of <br /> ❑ Ilidding I ank ❑Other Dispcnal Compouenl(cxplmn) Ocvmee <br /> V.Dis ersal/1 reatment Area Information: _ - <br /> - <br /> Design Flo (gpr0 --rid;Applieatiom Rabid; I D i Uispenul Ara Regemcd W) Uispenvl A' a PloPoscd(sl) SystLm Hlevauon <br /> Vl.Tank Ilflo o <br /> C Ipicuy air �dhom 1701 m Manufaciurcr <br /> nns ( limits <br /> Gall m <br /> aw <br /> Lnke elm r6 lanky -.. _ e Z a m <br /> N <br /> w 4 <br /> S i iI htldnrSrT im k O ) _ w <br /> n g Clhrmk, <br /> VII Responsibility Statement I,tile undersigned,assume responsibility for installation of the I oW I S shown on the attached plana. <br /> - °f M�/[v1PRS NumLi I's l'icss Phone Vuc� <br /> Plunibe-r's Nanw(Print Plumbe[s Signature i� f ✓7 7 <br /> r , <br /> '' ,�51�)/��� J�� L 76511 "G <br /> ]Ade �.a -- — - _- <br /> Plumber's Address(Street,City,Slate,Zip Code) <br /> VIIL Countyll)cpartment Use Only - --- -- <br /> � <br /> El- Disappmovul Permit Fcc Late Ixucd � Issumµe1 at naWrc <br /> Vf Approved ���- �-Ny� <br /> Owner Given Reason for Broad 4 3le2 -5q6 <br /> Co <br /> IX. nditions of Approval/Reasons for Disapproval <br /> _- - �- Allarh to enmplere glans fur me Sin"''mrd bnW to lheCnnit} Irnl root leas lhnnallE. Il inchesm <br /> SDD-6398(R.0l/07)V alid thnr 01/)9 <br />