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�ram4Srl County <br /> Industry Services Division Bun el <br /> '6 }o`` 00 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> S p 14P.O. Bax 7162 <br /> s r 1 Madison,071 53707-7162 <br /> Sanitary Permit Application Sure Transaction Number <br /> In itoomdus.with SPS 383 21(2),Von.Adm.Code,submission of this form to the ,.prude gavanmunW unit <br /> is required prior in obtaining a somas,permit. Nae:Application forms for aasowncd PCaWTS are submitted <br /> the Department of Safety and Professional Services. personal information you provide may he used fa secosday Project Address(if different than mailing address) <br /> psuposes in useanduuo with the Privacy Isw s.15. I nn,Stas. 9697 Danieli 70 <br /> 1. Application Information-Please Print All Information <br /> Pmpaty Owner's Name Fust 0 <br /> Township ofDanieb 07-0062-38-17-21-505-002-018000 <br /> Property Owner's Mailing Address putsany I iaxn <br /> 9602 Dammis 70 <br /> Goys.I.m 2 <br /> City.SimeLip Cade % 'A <br /> Pbora Number . , Section 21 <br /> Sirat,Wl 54872 (circle one) <br /> T38N R17 Hot® <br /> 11.Type of Building(check all that apply) 1-otM <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms I Subdivision Name <br /> ®Publie/Commereisl-Describe Use IJwA/ �0.�' HI«kp <br /> ❑City of <br /> ❑Swe tNrced-Describe Use ❑ Village of <br /> CSM Number <br /> Cm.Vol.J Pg.69 ®Town of Duniek <br /> III.T of Permit: Check only one box on line A. Complete line B if applicable) <br /> A. ® New System ❑ Repl.1 System ❑'roamuent/Holding Tank Replamtrent Only ❑ONa Madif extra in Existing System(explain) <br /> B ❑ Pmnit Renewal ❑ Permit Revision El Change of ❑Penn it Transferto New List Previous Permit Number ad late kased <br /> Before rxpow. Noodles, Owns <br /> IV.Type of POWTS S tem/Com nent/Device: Check all that apply) <br /> ❑ Non-presusood lmGrmmd ❑ PrasuvN lm-Ground ❑ Al-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<2A in,of suitable soil <br /> ® Holding Tank ❑Causer Dispersal Component(explain) ❑Pretreatment Devioe(explain) <br /> V.Dis ersaffreatment Area Information: <br /> Iksign Flow(gpd) Designs Soil Applicaion Dispersal Arta Required(s0 Dispersal Area Pmposed(s0 System Elevation <br /> 426 Raggpds0 No Na No <br /> Na <br /> VI.Tank Info Cameilym <br /> road <br /> New Troika (;al1�f::inine Tanks Gallons Imus MamfnGum r <br /> sU U 1 <br /> Septic in Holding Tank 2000 2000 1 Wieser Cnnctete <br /> Doing Chamber 111 0 ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assume responsbilty for installation of the MO shorn oa me absorbed plans <br /> Plumber's Name(Prim) PI MP/MPRS Numbr eBusiness Phone Number <br /> Davton Daniels s ngvptp W7086 715-349-5533 <br /> Plumber's Add.(Snot.City,Stine,Zip Cade) <br /> P.O.Isms 326 Siren VVI 54872 <br /> VIII.County/Department Use Only <br /> PO <br /> Approved ElDisapproved Pamir ree Date <br /> lsued Issuing Agrnt Signamr< <br /> wtrcr Given Roman fm Denid f 37sdo <br /> IX.Conditions of Approval(Ressons for Disapproval <br /> RD ECEIVEnR <br /> Attaaanrompku perm for tae a)stem•N avbe,a to rot CwarY soh as Aper wrlm wag resell is I <br /> SURNETTCOUNTy <br /> ZONING <br />