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eomrttert:eml.gov Safety and Buildings Division Coon <br /> u <br /> 'Wisconsin <br /> a Able 201 W.Washington Ave.,P.O.Box 7162rn G7� <br /> i sco n s i n Madison,WI 53707-7162 Sanitary Permit Number(m be filled in by Co.) <br /> D"Ftmont of Cornmarce 3 a a <br /> Sanitary Permit Application State IranInachon Number <br /> In accordance with a.Comm.83.21(2),Wi.Adm.Code,submission of this form to the appropriate governmental I / <br /> unit is required prior to obtaining a sanitary permit Note: Application forma for steto-ownd POWTS are project Address(if different than mailing address) <br /> Fersonl i <br /> submitted m the Department of Commerce. nformation you provide may be used for secondary <br /> 1AWPOICS in accordsuce with the Priya Law a.15. t m),Stela. / � ryry�� pp <br /> I. A Bcation formation-please Print AR Information IV <br /> Froperty Owner's AMC <br /> Parcel#0 7 0 A d d 40/N /.96" /s— <br /> FD• ne Nt Lori C3al�I ((S ' <br /> Property Owner's Mailing Address Igo 096 - 0/-0046 <br /> 70 7Prep"yLowhmba8-90.5 -01-� <br /> l�i7S�er (�srK Ga. Grvt.Lot <br /> City.Stere Zip Code Phone Number <br /> ys v, Seetimi /3 <br /> zneQ/ah4 Irl �. Al H6,1d 7 (circle one <br /> IL Type of utg(check all that apply) Lot# T 40 N; R /4' E o6) <br /> 1 or 2 Family Dwelling-Number of Bodrooms 3 S' Subdivision Name <br /> Block# <br /> ❑PubadCommer4ial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 village of <br /> C,G✓Jen Et/a7'YJ Town of .Site 1� <br /> IIL Type of Pergtit: (Check qtly one boa ten Hnc A. Complete tine B if applicable) <br /> A. jo <br /> New Sye(errt 0 Replacement System ❑Tmatmmt/Holdmg Teak Rep <br /> lacemwt Only ❑Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Pemrit Transfer to New List Pravions Permit Number ad Date Issued <br /> Before Expiration Owner <br /> IV,Tof PO S S bem/Com anent/Device: Check all that apply) <br /> 0 Non-preaaru¢edlnGroud 0 Preaemixed I"Ground 0 At-G-de 0 Moned>24 in.Of suitable$oil 4d Mound<24 inof suitable soil <br /> 0 Holding Tank 0 OtherDipetaal Contpow a(explain) 0 Prcheaunmt Dcvice(captain) <br /> V. Wren tln Area hiforneathes: <br /> Design Flow(gpd) Design Soil Application Rate(gpdat) Disposal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> YSO <br /> . 9 tiro Soy <br /> VL Tank htfo Capacity in Tote) #of Mard'acNrer <br /> Gallon Gallons Units y� <br /> New Tanks l;xistirg Tmils e 0 U •o <br /> in a rn i..C7 ZS: <br /> SeRw wxoklmg Tudt /000 /000 <br /> Dosrg Chamber 00 <br /> doo <br /> VIL Responsibili Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name tkymp PlumberPalms MPMIPRSS Number Bueinna Atone Number <br /> R/e% Ir1/o /e�nJ e L/n daCs~-�Sl 7/5-866 /!/J`7 <br /> Aumber'e Address( inset,City,State,Zip Cade) <br /> 7 6 0 /f/w 3S G!/CbS2/r✓ W17 <br /> 7 stl893 <br /> IL Coun /De artosent Use Ont <br /> Approved 0.Disapproved Permit Fm 77--�� 1Date Issued issuing em Signature <br /> O;OwnerGiven Reasonfor <br /> l)enal $ �'( V <br /> DC Conditfi u o,Approval/Reasoraa for Disapproval V w <br /> Albeb to eosepkte pterwfarthe systew and subdt tithe County oily on paper we ease than 8 ars x 11 inch in ate <br /> SBD-6398(R.01/07)Valid tlau 01/09 <br />