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Safety and Buildings Division Coun(yc/� /��+ /� 201 W.Wahine on Me.,P.O.Box 7162 Ju r <br /> ® iSCO Sin W. <br /> W.Ifinsn.n Me.,P., B2 Saoiury Parmit Number(to be filled in by Ca.) W <br /> Department of Commerce (608)266-3151 5 .6 ?�� <br /> Sanitary Permit Application State Plan LD.Number { <br /> In aemm wiW comm 83.21,Wis.Adm.Code, xmord information you Mvide <br /> may be used It,secondary purposes Pnvary law,s15.04(1)(m) Pm <br /> role/'Add'rt/ss2(ifdiffeent Wm <br /> an ailing adde,ss)r� I <br /> L Application Wormation-Please Print AB lnformztian '�(V�(I✓ W Ld QsGff ZO/.c 0 <br /> c ' <br /> Properry Owner's Nome Patcc]R Lath Block# <br /> PC L V eI <br /> Pmpury0wtcrs Mailmg Address Propetry Location )-t/DO <br /> Q J-OM1(-Q t/ <br /> Ciry,Smre !/� Zip Cade Phone Numbe <br /> r —1 %, %. Section JV <br /> l y CJZ- •G <br /> 7-Q/ �� TJ4_N: R�(Boed) <br /> ' pe of.uiIding(uheck all that apply) '2 <br /> 1or2 Family Dwelling-NumberofBcdmone J Subdivision Name CSM Number <br /> pubfidCommemial-Describe Use R '' � <br /> Sure Owned-Describe UseC'ry_ Village Towtuhip of1r yL� <br /> IIL Type of Permit: (Cheek only one box on Bne A. Complete Me B if applicable) Of)-Qa <br /> A. Ncw System pacernent Sysrem� Treamcnt(Holding Took Repl==ns Otdy Mer Modification to Existing System <br /> B. Prmis Renewal ptrnsi,Revision CMoge of P.n.,T=kr m New wtPtsvious Permit Numberaud Dwc Issud <br /> Be for apinnian Plumber Owner <br /> M Type of POWTS Svslem: Check all that apply) <br /> Non-Pmssunr� Mound224 in.afsuimblesoil Mound<24in.ofwiublewil At-Grade Single Poss Sand lifter <br /> Com so c WNmd Ressuriud InLmutd Holding TankPcv Flo-s Aerobic Treauvem Unit Reeirculaung gond Filnr <br /> Reci.hting,S .Iheft Media FilWr t Iung Chamber I)rip Line Gravel-loss R (Dther(ealain) <br /> V.D' era.Vfreatment At.Information: <br /> Design Flow(gpd) I Deign Soil Application Raw Dispersal Area Requited(sf) .Dispersal Ares Proposed(s0 Syme Movafon <br /> ,� • 7 %3 9,1,Sy - 9o,8r <br /> VL Tank Info Capadty to Toul Number Manuf d., Prefab site Steel Fiber Plastic <br /> 0.11. Gallons of Units Concrete Cansouned Glass <br /> New urfva <br /> Tutr Tank <br /> Squca Rol4iug Teak JO -TA", f <br /> AvoGeTmweot Uvi� <br /> Dwrivg CTaniaw <br /> Va.Responsibifi Statement-I,the andersl ued,asmmer nsfbility for Installation of We POWTS shown on the attached plan, <br /> %umbers Nurse(Me,) narnl,er s Si'.. MPNPRS Number Business Phone Number <br /> Plumber's Addrus( ores,City,State,Zip Code) <br /> " , <br /> VDL Courta artment Use Onl <br /> Approved Diwpproved Sanitary Penult Fee(Includes Gos odwarer Dare Issued tssukig Agens Signuure(No Starryu) <br /> Surehat Fee) A S > <br /> Owner Given Recon for Denial <br /> .Conditions of Approval/Reasam for Disapproval <br /> f" # [pavg/Yahaa w11t A.N. 9-�13 p 3,ao, D <br /> Deck y cl,a.bdn ;, Z row5. <br /> SEP 2 5 2013 <br /> Apaa—plete plana(.1M County avly)far the synemwpaper vat kss Wan aln•11 Nr lass �^OUNN <br /> BURNE V <br /> ZONING <br /> enn_Aaoe ID ni MIN <br />