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Safety and Buildings Division Court <br /> ` an ar 201 W.Washington Ave.,P.O.Box 7162 u.False'11`' <br /> iseonsm Madison,W1 53707-7162 SanitaryPemlitNumberput befilled inIt,Cal <br /> Department of Commerce (6(1x)266-1151 ry <br /> Sanitary Permit Application Smile Plaa1.D Number <br /> In accord with Comm$3,21,Wis.Adm.Cade,personal information you provide <br /> an,be used for awards,purposes Privacy Law,al 5 n4(DQn) Pre,ect Address(if/d�ltferen�tldmailing addmss) <br /> I. Application Information—Please Print All Information <br /> Property Ownei s Name Parcel q Lol q Black M <br /> vlxya Gebn.l 7r,5,,1 ofd( 4p/ o! <br /> Property Owner's Mailing Address Property Location 6av LoT ' <br /> add 17NO /VW <br /> S rr^ /irr fh,.✓a Ln Nb '/.,f5.) i Section <br /> City,also, Zip Code Phone Number �� E I ,� <br /> a ur SN830 t40 N, R/Sonu�y ) W <br /> It.Type of Building(check all that apply) <br /> 1 or 2 Family Dwelling-Number of Bedrooms ff Subdivision Name CSM Number <br /> ❑PublidCommerclal-Describe Use <br /> ❑Stale Owned-Describe Use ❑City ❑Village&awnship of J_ nn <br /> 111.Type of Permit (Check only one box on line A. Complete line B ifapplicable) <br /> A' IgNew Systan ❑kept acemem System ❑TreatmenVllolding Tank Replacement Only ❑ON a,Modificainn to Existing System <br /> B. 11 Permit Rent ❑Permi[Revision ❑CM1ange of ❑PermitTmnsf to New List Previuus Pemlil Number and Date Issued <br /> Before , Final on Plumber Owner <br /> IV.'rypeof POWTSS stem: Check all that apply) <br /> AlNon—Proamusec N-0round ❑Mo und'24 m.cfsuitablesed ❑ Maund<24 m.afsuirablesail []At-Grede ❑Single Pass Sand Filler ❑ <br /> CnnstmaMWelland ❑Ptesmosedln-Ground ❑ Holding Tank ❑PmtFilter ❑Aerobic Tactancnl Unit ❑Recirculating Sand Filmr ❑ <br /> Recirculating Synthetic Mediu Filter ❑Leaching Cbamher ❑Drip Line ❑Gavel-Ins Pipe ❑ONer(explain) <br /> V.Dis eraal/I'reatment Area lnfnrmatioa: <br /> Design Flow(glan Design in Application Ram(gpdat) Dispersal Area Required(so Dispersal Arealimposed(sn, System Elevation <br /> 600 . 7 1 8S7 8'7/ !y. eq <br /> VI.Tank Info Capacity in TotalNumber Manufacturer Dead, Site Steel Fiber Plastic <br /> Gallons Gallon of Units Concrete COnsnocred Glass <br /> New unfi.g <br /> Tema forty <br /> Sepucnr..1oyTen& !}1'O /a Iv, <br /> f Cs <br /> AcrabioTrcatmcnt UNt <br /> w,mscbmmhn, <br /> VII.Responsibility Statistical-I,the undersigned,assume respnnaibility for imtslletion of the POINTS shown an the attached pains. <br /> Plumber's Name(PrintI Plumber's Signature MP/MPAS Number Rosiness Phone Nmmbe, <br /> Rle2 No IIIc Cash)2eP wtts�si s SG6- vrr <br /> Plumber's Addrtaa( Ireek Ciry,Smtq Zip d <br /> '47760 #—L 3f websfre- cvl: 8"i3 <br /> V . hours/Ile artment Use Onl <br /> Agoras, ❑Disapproved Sanitary Permit Fee(indutles Gauntlwatcr Date Issued Bsuin Signature nStnmps) <br /> SumM1erga Fw) /VC/, N✓ /7 y,a O� <br /> ❑Owner Given Reason for Denial rC✓VT' Ja-Y <br /> Us Conditions of AppmvaVRemons for Disapproval <br /> &UI Sf0✓J Tu 406A'/iaa cF DR*WP40I A�So VxaxWYes Tva� CdaW3oe. <br /> -zafTyob <br /> AXacb cnmpah Plan Ire Nn Canty only)for Ile fynem an pPv our lua Mm 60 a 11 ineae,in abs <br /> SBD-6398 (R.01/03) <br />