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gopptpywrco pi,�py Safety and Buildings Division Coonry DvVI'1' <br /> AblIkA201 W.Washington Ave.,P.O.Box 7162 dJ <br /> FIs, ncsiR', Madison wl 53707-7162 Sanitary PermitNumber(mxfi8ed nbyCo.) <br /> VV ttsoi 532163 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with e.Comm.83.21(2),Wu.Adm.Code,submission of this farm to the appropriate governmemd (a 7/ 33 <br /> unit is required prior m Nota'. Application s sanitary permit NoApplication forms for etato-ow"d POWTS are Project Addro a(if ddfmau than ming address) / , <br /> submitted e Department of Commerce. Paraoral reformation you provide may be need for secondarypurposes / yn,� W <br /> m th <br /> is accordance with fm Law,s.15. m 1 Stab. 7377 N. 6ASS AK p`Y <br /> L Aplification htfarsa8an-Please Print All hdormadon <br /> Proputy Owner's Name �}- Parcel k <br /> Ro6e,,rt A. Reese � 71 �� 0/8 3321 01806 <br /> Pmpaty Owners Mailing Addmes property Location PGj- IA) <br /> 7,377 N. 6&55 1.eKc io6a Bertha[ <br /> City,state t / zip rC/odfe� Phone Naber ��,(�Yy Y'+ S� 21 <br /> Webs-6 Wl STUN T3N; RJt�)ZerW <br /> SIL Type of Building(cheek all that sp*) Sabdivirim Namc <br /> Int s <br /> 1 or Family Dwelling-Number of Bedroom! z <br /> tp <br /> Block a <br /> ❑Pablir/Commmcial-Dmer3e Use ❑City of <br /> ❑State Owned-DosonlicUse CSM Number aM <br /> ❑-,�Village,of 1' <br /> Oa Town of eanov, <br /> III.Type of Permit: (Check mdy one ban m Hue A. Complete Rate B U spplksble)0 - - - - - - - <br /> A. Now System Replwaeant System ❑Tramacealloldmg Tank Replacement Only 00&.Moddication to Existing Systmn(ecpla-) <br /> B. ❑PermitRmawal ❑Permit Raviaion ❑C6aogeofpl®ber I ❑Pewit TrassfermNew Listftev—Perm Rberand Dateluaad <br /> Before Expiration Owner <br /> IV.Type or POWTS t m/Cas VDevke: Cheek all theta ay <br /> ❑Nm-pMmnzed Intimaod ❑Pmsamaed In-Gnoe d ❑A4Caade ❑Memd>24.,,rof sueabb wil 00 Mored<7A ie,of suitable soil <br /> ❑Holding Tank ❑Otho Dupexal Component(explain) t]Aet catmantDevice(explain) FAsr <br /> V DiamensIfFrestment Arcs hifot s"L <br /> Daign Flow(gpd) I Deign Soil AiMlicsboo Rate(gpdet) Depend Am+Ro"red(at) Dbpenal Area Proposed(ef) System Elevation <br /> 00 1 p,7 1 i50 1 /So 1 - Sup vo <br /> VL Tank Wo Cnaeatyym TOW Units Manufacturer <br /> GaRNew Trus Bdang Teak1 <br /> m � <br /> Septic-Hol TankS — !�V / �//�'EjL ✓ <br /> DougCwmbe O - fioSO / I ✓ <br /> VD. Stateammt-T.the amderd ed,si m e,respoexilillity4br i"INHOARD of the POWTS show*onthe attached •as <br /> Plumber's Nemo(Fria[) Ptnmttr'e DIdMP"Nnmbe Bmmms Phone Number <br /> (lie K uFFwtetn 'Y�(/l 2503/8 /5 7/,6 -3 V <br /> Plumbers Address(Sleet,City,State,zip Code) <br /> 9 m w V E ✓IN roe <br /> VILComi artment Use Onity <br /> Mr <br /> AMmed ❑Di gWoved PermitFae Dam Issued <br /> / Issuing <br /> ❑Owns Civet Rseon for Danielg 375 /(P 117 62 &tI <br /> J� <br /> DCConmtim*ofApprw*auRe.mmfonDisapproval 3 GvA{pAteTMErVr WI&66 Q- AA)K sr- A - p"k.... <br /> An"to ompbb tlussorawMM ardod"talb Crays*ear papw esu bssthsas kir III hrhmin dna <br /> SBD-5398(R.02109)Valid thin 02/11 <br />