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Safety sod Buildings Division county <br /> 201 W.WaSWngt0n Ate,P.O.Box 7162 U n <br /> M 17162 <br /> n zis83(tQ be filled in byCo.) <br /> Department of Commerce Stuc Plan LD.Number�{-- <br /> Sanitary Permit Application Z 707 1 <br /> in accord with Comm 83.21,Wis.Adm.Code,personal infomsation You Provide <br /> may be used fm;ecmxley purposes Privacy Law,sl 5-040)(m) Proj;t Address(if dpilfe�ent than mailingaddress) <br /> CO.W o 1`m• -z- <br /> 1. Applieatioe lnforreatioe-Please Prier Ad Ietormatme a -01-100 ( n <br /> Parcel N Lot N Block N U \ <br /> w Ws Name <br /> 71'eY- ar/ c d rht c35�po2oo/ 7 <br /> Property L UImr <br /> property ,['s Mailing Address <br /> !V _m+ Section 2 <br /> City�. jrue / �L(e � ZipgC.ade j Phone Number / ?,/� <br /> JC U 4 C r Z ��®�/!/ Y/ �I/"� �'�-3W� T J/ N; R-eE�) <br /> I .Type of Bedding(chkk an that apply) el Subdivision Name CSM Nmnber <br /> pH1 or 2 Family Dwelling-Number of Bedrooms /0/.71 O-' /Wle 7?'et de A•C)'. <br /> ❑public/Commemial-Describe Use ❑C;ty_❑Village�avmship of J?,Qde Gott <br /> ❑State Owned-Desmbe Use <br /> 111.Type of Permit: (Cheek only one boa a live 1 L Compi list B if applicable) <br /> A' J9 New System ❑Replaceormt Sysb— ❑Treamr®t/Holding Tank Repi;emem Only ❑Olher Modification to Exiuing System <br /> B. ❑Permit Renewal ❑Pemil Revision ❑Chase of ❑IiermitTnmfe m New <br /> List proviaus Permit Number and Dam Issued <br /> Before EgmuU r Plumber Owner <br /> IV. of P0wTS System Check all that alopm <br /> soil ❑At-Grade ❑Singlepariur <br /> Sd Filter ❑ <br /> ❑Nan-Pressurimdln-Ground us <br /> ❑Mod->2A iaofmnad wet IN Mound<24 m.ofsuiuble <br /> Cmrmwted Wetland ❑Pr nurircd m-0ronal ❑Holding Tank ❑Peat Filosr ❑Aerobic Treanue t Unit ❑R;vcolating Sand Filter ❑ <br /> R;irculating Synthetic Media Filter ❑Leaching Chenber ❑Dnp Lme ❑Csawd-less Pipe ❑odur(explain) <br /> V. ' rentment Ara leformandoa: pal Arm Requimd(st) Dispersal Am Proposed(sf) Syaern Elevation <br /> Design Flow(gpd) Design Soil Applicslion R.WgpdsQ �, 5S <br /> �. y5 �om• 7S loco. / <br /> NT Tank Info Caparary m Toni Number Mmrdactiaer Prefab site Sred Fiber Plastic <br /> ber <br /> Gallons; Gdlom OfUnds Concrem Comtnscted <br /> New Fxising <br /> T.oks Tdn- <br /> geP&a Iloidog Teck �� � {(V/•�5 e( <br /> A.I.Im Treerma Urns Q"s 4c) <br /> DosingCMUker lj <br /> VII.ReWosibility Statement-1,the eaduaipe4 aewme rWawROly For mens of the POW'M show.ow tha attached plass <br /> MP/MPRS Numbs Business Plwne Numb; <br /> rij <br /> Plumber's Name(PPlum 's Si <br /> /3�6SS his S3 <br /> Plumber's Address(Street.City.Sum.Zip Code) �Ed�'r G 41 t c ` rT /11,4-14S <br /> VI .Cosa rtnLmt use Sanitary p=it F;(mdadas Groundwater Date Lseod tsi (No Stamps) <br /> Approved ❑Disapproved Surclurge F;) /� <br /> C3 Owner Give,Reason f;Datil t^ 300 13 SU1�6`IA9 <br /> IX.Conditions of ApprovaYReason+tor Disapproval <br /> pa.c►eaopker plor(m tie Coeety oalY)�me ryaho m pyer aW lw ibao ala:11 fordo fe she <br /> SBD-6398 (R.01/03) <br />