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Ccarw aree.Wl.govn Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> ' nc�! Madison,Wl 53707-7162 Sanitary Permit Number(to be Ued in by Co.) <br /> Sanitary Permit Application Stare Tnmusclon Num," <br /> In accordance with s.Comm.93.21(2),Wis.Adm.Code,submission of this from to the appropriate governmental A mD Z <br /> unit is requited prior to obtaining a sanitary permit. Note: Application fosse for stdco-moned POWTS are Project Address(if dillacat the i mailing address) <br /> submAted to the Department of Commerce. Personal nifesmabon you provide may be used fu seonndary <br /> purposes in accordance with the Privacy Dow,a.15. 1 m State. 30752 Me"rrs Law a <br /> L A 'm Infaaatien-Please Print All in[oraadon <br /> Properly Owner's Name Parcel# <br /> Carol Beck 032 5219 03900 <br /> Properly Owner's Mailing Address Property Location <br /> 30975 Madison Avenue <br /> Govt Lot 1 <br /> City,State Zip Code phone Number YS Yy Soctix n 19 <br /> Selbyrllle,DE 19975 (steres 1 CIQ <br /> IL Type of Bldlding(check all that apply) <br /> Lot# T 41 N; R 15 ❑E Q W 9j <br /> ❑✓ 1 or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name ( � <br /> Block# (v l <br /> Public/Commercial-Desrnbe Use �+ <br /> City of <br /> ❑State Owned-Describe Use CSMNumber ❑Village of <br /> Vol.9 Pg 149 ✓❑Town of Svdss <br /> IIL Type of Permit: (Check arty ate box on line A. Completefirm B if applicable) <br /> A. Now System 0 Replacem®t Treatmest/Holdmg Tank Replacement Only Other Modificative to air'in System(explain) <br /> Sym <br /> B. Permit Permit Revision Change of Permit Transfer to Lel Previous Permit Number an I Date tuned <br /> Renewal Hefare Plumber New Owner <br /> porsent/Device: CLwk aB Otat aVWo- / umnsd1n-G m <br /> A4Ckade Moond>24 io.of suitable vel Mound<24 m.ofew ble soil <br /> ✓❑Holding Tank ❑OPocr D pemal Compocent(eeplam) []Pretreatment novice(explain) <br /> V. ' ent Aad IMotmatiar: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) D)mpenal Area Required(at) Dwpwra l A&mproposed(af) system Rlev <br /> 300 <br /> VL Tank We Capacity in Total I #of NLwdact a Material <br /> Gallom GaHom Usriu <br /> New Tool. HxisMg Tad. <br /> SepticorHoWhg Tank 1333 2000 1 2 1 SKAW PrefabConorel <br /> Dos%Chanbc <br /> V D.Posposmilaffily Shtemmt-1,We undersigned,summer respousitmfor installation ofthe POWs sbown on the attached plans. <br /> plumber's Name(Print) 's S' MP/btPRS Number Becomes I hon,Number <br /> Ross Toltender / 051954 (715)M 8070 <br /> Humber's Address(Street,City,State,Zip Coli) <br /> 27230 Jamison Road,Webster Wt 54893 <br /> V11L Corer aataent Use Only <br /> _'Approved I _DisapprovedParitF <br /> mee Date bsoed / Issumll germ : <br /> _Owner Given Reason for Denial $ <br /> 0 A, 11�/ <br /> IX.CMtima of ApQprov .JV <br /> /J,r : �o Foto. .SntL q,65Wrlolt) Get.(. dn) T74 IS AV7: <br /> Attach to melaels Plamforthr sysh o ad submittoWe County only onAper not ren Wan 9 ter III hKbn In size <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />