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commercemi.goV Safety and Buildings Division County <br /> 201 W.Washington Ave,P.O.Box 7162 ave e n Z <br /> i seo n s i n Madison+Wl 53707-7162 Sanitary Permit Number(b be filled in by Co.) <br /> Department of Commerce <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Conor.8321(2),VPs.Adm Code,submission of this form to the appropriate governmental <br /> unit is regnimd prior to obtaining a sanitary permit. Not-: Application forms fa state-owned POWTS are Project Address(if differem tan railing address) <br /> submitted to the Department of Commerce. Personal infi nmztkn you provide may be wed for secondary <br /> purposes in acmndance with the Privacy Law,a.15. 1 m Stats. �/'d 5 eG•IL AV Lo <br /> L A licatim lnfoamation-Please Print All Information <br /> Property Owner's Name O„a Parcel# <br /> 571CVe 1sa4csovl O,lo 9/ - /�SoO ✓VJ <br /> Property Owner;Mailing Address p Property Locative <br /> 3 GOO/ 0,- Rol <br /> - � Govt Lot <br /> City,State Zip Code Phone Number <br /> /tl 3 y~ v, sedan ) <br /> G 4 A n /v SS (tick one <br /> IL Type of Building(check all that apply) Lot# T y0 N; R / w E o15 <br /> D 1 or 2 Farm Dore S division Name <br /> H Bm8-Number ofBedroome <br /> 7 Block# i ) <br /> ®PubadCommercial-Deecnbe Use TrAi/•ot fr I /7 0Cityor <br /> /f.e0gw I <br /> D State owned-Desmbe Use CSMNumber D Village of <br /> ®Town of Cyr k4h s <br /> III.Type of Permit. (Check only care has on line A. Complete lime B if applicable) <br /> A- <br /> 0 Newstem <br /> Sy .qt v� <br /> Replaccmrnt System ❑TrWmrnt/HoBing Tank Replacement Only ❑Other Mod'd'ration to Existing Systm(explain) . <br /> B. D Permit Renewal D Permit Revision D(range omumber D Pamst Trawfer to New ListPmvn w Permit Numba sod Date Issued <br /> Before Expiration Owner 1 <br /> oqw <br /> IV.Type of PORTS Com ent/Device: Check all that apply) <br /> S Non-peseurbad In-Ground D Prenmixed In-Ground D At-Grade D Mound>24 in of suitablesoil D Mound<24is of <br /> D Balding Tads D OtherD sim al Compor mt(expbb) ❑Prot atmrnt Device(explain) <br /> V• Ixsal/I'natment Area Warmatim: <br /> Deign Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(et) Dispersal Arra Proposed(sl) System Elevation <br /> Icon 1 . S S ,(yoa 9r/.A -7 <br /> VL Tank Info Capaeity in Total #of Manufacturer <br /> Gallow Gallow Unica $ o <br /> New Lnh Exaturg Tads <br /> 8 a_ <br /> N� VJ {L V• Vi <br /> Septic or Bolding Tort` <br /> Doaig Chamber <br /> deco coo / kFrc�.r <br /> VIL Rapondbitity Statement-f,the undersigned,assume mponsibr7ity for installation ofthe POWTS shown on the attached plana <br /> Plumber's Namc(Print) PlMW6 Signattue MP/hen Number Bwme-Phone Number <br /> 'X'C*qo� ams 2zs I 71r. <br /> Plumber's Add—(Street,City,Stam,Zip Code) <br /> 07UD 3s 3 <br /> VLIL Coun /De .,imam Um OnI <br /> ICAppreved D Ernapprovd Permit Fee Dambsud Issuing ngnamm <br /> ❑Owner Give Reason forDaial S 3U5f Eli r <br /> DL Conditions of Approval/Rea+ons for Disapproval <br /> NJovjc: Evu#4 646;c. Ia <br /> ic. nK MCGG1 `•l <br /> $ St r./Al� Cfifiereg a IkHt B3 Ar the Ante <br /> OF Elie Orf916741 4pfft4l em4lnsl;.tll fors - 9////'9 <br /> NS ofand wbnb — C <br /> Arnim b ea- an,pkle p6far the ryas- W b the County ady on pap.not kw tea 8 to a 11 inch.bruise <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />