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Colors C.WLgOV \incl),uud 13uilJnips Oivisiun Count <br /> v <br /> 201 W. Washington AA,,.. P.U. liox 7162 61//aN e. <br /> 4t <br /> iscons i n Madison, WI 51707 7162 Sanitary Pcrmd Nunthtt(to be filled in by('o) <br /> Department of Commerce <br /> 5� 1028 <br /> Sanitary Permit Application --- Stalc,'rarlaachmiNun'hcr --- <br /> In accordance sviW s.Cumin.93 2](2).Wi,.Adm.Code,salon fission of Iles form to the appnrIola l,gnecrmncnLlI "Tt� <br /> unit h required 11 prior to obtaining a sanitary permit. Note: Application fumes for aWlc-uw ucd PO\1"fS arc Project Address(ildil7cradthannmiling:Wdress)— <br /> suhmiticd to Ilw Department of Commerce. Personal information you provide may be used for secondary <br /> Nelm oMancc wall he Privacv law,s. I AOJI I I(m),Slat.1. Acation . <br /> Information-please Print All In furmatinn pp�� // �' //'' <br /> I'nryrcrty Owner a Nome sl at Te C-OVYtj <br /> /^ Parcel a 0/2.917 800 a c 70) <br /> 1}opcny OwnoLi sMailing AdJ�a. / a — y! D/.Z 9f 710$/00 (7/) <br /> e'../7 3 4^44 e Property Location PC --- <br /> Cily/Stale 1 Cr (lost.Lot <br /> ' Zip(inlc - <br /> r J Phanc Number �J- NCd '; . <br /> sAprevlecJ ,v �5 /a6 6S!_�g J ,cenimrl3 <br /> �_/ 70�' 1j1'ulc one <br /> 11. Type of 13uilding(check all that apply) Lau: --. .I. .y0 N: IL /•� I(1 W or lamely Dwelling-Number of l3cdnuons Q��! SubJivisiun❑ <br /> �_ 131ock 11 ¢,.a� `f"/`fi �a Y V•Public/Cnrtc <br /> unmial-Dcxm ibc Use '/ <br /> e L <br /> ❑ Cily of ._ <br /> El <br /> Slate Owned -Descriln:I Ire -.-_.. t— ('S.\I Numhcr ❑ Village ul �— <br /> �_ �Yirwn nl'. V /7G KSO_/V <br /> Ill.'1'ype of Permit: (Check only one box oil line A. Contplele line 13 if applicable) - <br /> 1. - <br /> New System U Replacement System ❑ 'I'rcabucnl I lolJing'I'ank Rcplac<mun Only U Wier Modification to lixisfing Swslcrn(cgrhiin) <br /> B. U permit Renewal U Permit Revision U Change ol'Plumber U permit Trane(ur lu Ncw List Previous Pemrit Numbered Date Issued <br /> Be6rm hnpiratim. <br /> Uwaicr <br /> IV.'fv a of POW'1:S Svstem/Cma onent/Ucvice: (Check all it a r Iv) <br /> n-Pruni. urized In-(around U Pressmized lo-(innmd ❑ :\I-Gndc U Memel -2d in.ul suitable xod U Mound <br /> '24 in.ol'suilablc soil <br /> Holding ❑Other Dispersal Component(explain) <br /> ❑I}ctrcahncnl Ucviec(cxphlin) <br /> V. Des crs:dlfreanncnt Arca Information: _- - -- - -"---- <br /> Design Plow(gpd) Design Soil Application Rate(gpdat Di'll"'al:\ma Rapured(sl) Uis Area Pru -- <br /> DI nrsal pascd(sl) Syslwr 1:'lucaloo, <br /> V1.Tank Info Capacity in 'total sof - <br /> Gallons Manufacturer <br /> Gallons Units u c <br /> Ncw'I'wJs liaisling'lank, t 2 o <br /> v y -13 in <br /> Dosing Chmder --- <br /> VII. IZl`Sp011a1 hetet.StIlelncat- 1,the undersigned,assume rvnponsibJihfor imtallaliun nl'Ihe 1'O\\'rS shown an the allneh nl plans. — <br /> Plumher's Name(Print) Plnmher's Signamrc <br /> � PRS Number Breliness Phanc Numhcr <br /> �- i�oem �a� �MP/MZz'lumber's Address(gtreL't.City.Stale,%ip Codd -- <br /> C� GtJ,V7 ✓��/a�17� -- --- <br /> VIII.coun Me artment Llse Only <br /> .Approved U Disapproved Pcrmil Pcc/� Uanu IxsuuA Issuing: •n rgwturc -------- - <br /> ❑ Owner(iivar Reason lis Denial <br /> \C25 D7 <br /> IX.Conditions of Approval/12easons for Uisepprov:d --- -- —_—_—_ <br /> etc l6s4rw Gxc arc Dol& Bfarii zo-' zo 4 Lor 71 <br /> Attach to romplale plaru for the ayslnn:nal sulanit to rlw Counry Dory on lunrr oar kxv than a to a 11 Inclws br raze <br /> SBU-6398(R.01,07)Valid 11,to 0i,O9 <br />