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_ As <br /> Sa es and Builtl e , Division <br /> �C pr.. - <br /> _i. W. Washington A e PQ Boz] 5 rAdd.... <br /> d .. <br /> ������ Madison, WI 53107I62 ST Add ss --{ <br /> Department Gf Commerce Y111.d /tort SCA <br /> Sanitary Permit Application sa""'yIs—,N°mho' <br /> In accaN wide Comm 83.31, Wit,Adm. Code,pn5oral laformaoon you provide F1 Chea if Revision P'h✓ C <br /> _ may be used for xmnalafy purposes Pri"' Law.siS.Mi X2262 <br /> - <br /> 1. Application Information-Please Print All Informatbn - r Sure Olnj D�n ft <br /> Property Owner's Name J Parcel Number <br /> !(CITY + I'a $w4n�S{w2 0196-Alt?7- 077019 <br /> Property O-.per's Mailing Address Pmpeny Location <br /> —�V't' CDT t <br /> 630 / 6e O/G lam. s,S 17T 39 N 17 <br /> City,Sure Zip codePhpne Number Lot Number Black NamLer <br /> Subdivision.Name CSM Numbs <br /> Lf;sO 41< Mbf SSp/y 6S!— EfP9-6vas �9 /d ! <br /> R. Type of Building(check all that apply) !lGry <br /> &�I nr 2 Family Dwelling-Number of Bedrooms Cvgla,e _ <br /> I I Nibiir'Commcre al-Describe Use wnshi Drtn I E__(f_ <br /> Ll Sum Owned Nearest Road <br /> /✓I ads Nen Lk Aiu p <br /> In. Type of Permit: (Check only one box on line A (numbering scheme For internal use). Complete line B if applicable) <br /> A. 1 New 2 LlReplazzoom System 3 � Repiacemem of 6 '� Addition c, For Courtly use <br /> Swam Tark Only E.i,.a 5 sWrn L <br /> & ❑ Check d Sanitary Pm <br /> ediousl <br /> t Previously based Permit Noisier Daa Issuad <br /> .__ <br /> IV.Type of Permit: (Check all that apply)(numbering scheme iv fur internal use) <br /> ua ❑ Nan-Pressunatd In-Ground 310 Mound a]C Sant Flier 50 J Constructed Wedaod <br /> 22 C Pressune'd InGmurd al;K Noldin,Tark 68 C Slagle Pass 51 C Drip Line <br /> 45 C AOGrufc I6 C Aerobic Taos mens Urn 49�Ll Reece.fam, 30 C Ocher <br /> V. Dis ansa//Treatment Area Information: ' <br /> Design Flow("i) Dispersal Area Disperse)Area Soil Application femolarion Ram Sysem Elevaemn Finai Gmd: 1 <br /> Required Proposed RaW(Gals./Days/Sq.FI) (Min, Elevation <br /> VI.Tale Info Capacity In Tora1 Number Mmufacmre: Prefah Sim5ree1 Rber Plastic <br /> Gallo. Gallo. of Tands Concrete Caroaesed Glass <br /> flew ti,rilnoa <br /> Two, Tants <br /> scope or Rpldmg Tam 3DA0 <br /> Dosing(hammer <br /> VII, Responsibility Statement- 1,are under a ped,assume respn.ihdtly for iustaOaliun of the POWfS shown the attached plans. <br /> Floater t Name(Print) Plumber MP/MPRS Number � Business Phone Number <br /> 4ARPAl ✓s R ZZsss1 1 )13'- S66- 4K7 <br /> lumber's Address(Suter,Ciry,Sure,Zip'CMe) <br /> 2-7-7 (00 /-}w 35 <br /> Count ID e artment list 1 <br /> Approval C Disapproved Sanitary Permit Fee(includes GmurviwarerDue Issued I"on"_ at lgmatre uamps) <br /> Surcharge Fee) I' <br /> C Owner Given Itaaal Adverse <br /> tio <br /> Dearminan L�l/V <br /> IX. Conditions of Approvals Reasons for Disapproval <br /> Fkle PUN y1q( vkt' ,Lt4?6e krrAc4460 <br /> drnch mauls[pU—no 0,Caunry eal')for me ryum im papa tion Is.than glia x 11 Weha ip eue <br /> SBD-6398 (R. 05101) <br />