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commerce.wl.gov Salcey and 13uildings Dic ision Comity I <br /> 201 <br /> l fi 06 <br /> W. Washington Ac- I'O. Rox 7162 j4 0� <br /> Madison,WI 51701 71G2 seonsin Sanitary Q, <br /> permit Number(to he filled in by Co,) <br /> Department of Commerce /_ /-IPO2, <br /> 17Jl(/ <br /> Sanitary Permit Application Stale I'nnsaclinn Nunlher <br /> In accordance with s.Comm.87.21(2),Wis.Adm.Code,submission of this IitrIII to the approprialc govmunenlal <br /> unit is required prior to obtaining a sanitary punnit. Note: Application (onus fur stain-on ued PU\\"I'S arc fl'oject Address(il dil7erenl than mailing address) -- - <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy law,s. 15.04(Ilion),Stats. 8� ����e• ^ <br /> 1. Application Information-Please Print All Information O - ` <br /> 1'roporty(hvncr's`nine _ /^ �I'u)rcel A <br /> h,^ <br /> 1 .5 � 6 e h se. # ��-a4'I13—o�-36a <br /> property Owner's Mailing Address 1 - e �- - -- <br /> P g �[ /{n `` C, 1'rupert}'Location r� <br /> // w (� L 6 ✓ 7 _ Govt Lot ��-PG <br /> City,State /ip Code Phone Nwnhcr - Secliun <br /> e. <br /> 11.Type of Building(check all that apply) �7 I±.or© <br /> �or 2 Family'Dwclling-Number of Bedrooms 1;2I Subdivision Nan. ----------�- <br /> Rlnck <br /> —_. <br /> Public/Commercial- Dcsuibc Us. _ ❑ Cily of_ _.... <br /> ❑Stale Owned-(Ascribe lase CSM Nunlher - ❑ Village of _& / <br /> I11.Type of Permit: (Chink only one box on line A. C(inq)lete line R if applic:lble) ------ <br /> A. <br /> Ncsr System El Replacement Syslcm ❑ calntcnl;llnlJing'Lnk lieplan:nunl Italy ❑ Udler Modilicatiun to Existing Syxlan lcsplainl <br /> 11. El permit Renewal El ❑ ('b:wgc ol'Plmnbcr ❑Pcrmil'I'anxlcr In Ncw <br /> Pcrmil Revision List Previous Pcrmil Nunmbormd Dale Issued --- <br /> r <br /> Befin. apiralimt (hvuor <br /> fi <br /> IV.'ry a of mwi's system/Corn anent/Drvice: Check all that:m 1 IN <br /> Pn-aa-Prvssuried In-Ground ❑ PI'essm'ized In-Ground ❑ At-(trade ❑ Mound_24 in.of suitable snit ❑ Mound 24 in.ofsuitablc soil <br /> ❑ Iiulding'lanA ❑Otho Disposal Component(explain) _ ❑ t}otrcalmcnl mviec(expiain) <br /> V. Dis ersal freannent Arca Information: _ ---- <br /> Design Flow(gpd) Design Soil Application Rale(gpdsl) Disposal Atoa Requacd(sQ Uispecud Aro.proposed(sf) Syment <br /> VI.Tank Info Capacity in N1anulacturer - <br /> c <br /> Gallons Gallons llltils <br /> Ncw'I'wJs lisixling limke w � U _ h <br /> v <br /> ct V in � y w c7 a. <br /> Septic srµ" L''n�nk <br /> Ik+singChimhur - -- c6AIICI'C — ----- <br /> "- -- <br /> VI1. Responsibility statement- 1,the undersigned,assume rnponsibilitfor inxlallao'n,of the I'O\\"I'S shown on the attachtd plans. --- <br /> )'lumbei s Name(print) Plumher Sigoahac MPiMPRS Nun+ber 13usinesx Phnnu Numbco —_-- <br /> 4c)666r, 41A <br /> 1'umber's Address(street.City,Slate,Zip Code) - <br /> d S/ q —S //` e <br /> VI .C0 ty/Dc artment Use Only _ ---- <br /> Approved 0 Disapproved Porton pe-- D2:uc Issu..1, Isruing ct ,iptentim <br /> 0 Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to matplete plans roe Ihe.y,in, mid sul.uil lu it.Caunly anly un ryl.r nal leu Ihm+a m s I l Incl..ia.iae <br /> S13D-6.398(R.01,07)Valid thin 01,09 <br />