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�t.m+rcY1 n County yy//�� "� .rte <br /> +� Y Safety and Buildings Division - U P/r1 (/ <br /> •Ip$'s, o^� 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by co_) <br /> P.S Madison, W153707-7162 <br /> Sanitary Permit Application State Transaction"nm"" <br /> sr,d-ly-z6 < <br /> In accordance wish SPS 383.21(2),yls_Adm.Code,subeasnon of this form to the appmpdme govemmental unit <br /> required prior to obtaining a sanitary permit. Note_Application forms for state-owned POWFS are submitted to Project Address IT different than moiling address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used Cor secondary �F O Q�O• nr L�3-a N �� <br /> Purposes n accordance ,'th the Privacy Law,a. 15.04(p(m),Stars. <br /> 1 Application Information-Please Print All Information <br /> Pmpeny Owners Name Parra k <br /> (qre k7or7Lfe✓ 01-00,137-18-;0 -, 4t=60; <br /> Property Ownets ai ng Address r.[ _/ 1 ./ Property Locattuon —0/.3004 <br /> 7147 - <br /> ,/ J( YC¢T C[ Gent Lot CC <br /> city,sure Zip Code Phare Number Secfien <br /> Q0. U-l> /fl Y�✓lin7s `'s/-�e( -9S rz cicone <br /> Tj R F.or <br /> II,Type of Building( heck all that apply) Lot W - <br /> ❑1 ort Family Dwelling-Nmnber ofBed ramr, anodic man Name <br /> e.A9j�rr n Block4 <br /> Public/Comme¢id-Describe Use <br /> ❑Cinof <br /> ❑State Livered-Describe Use / � <br /> CSMNu>mpIs est / 11 Village of <br /> 1 -7 Vf J(/ l et ®Tounof r� <br /> I1LTypeof Permit (Check only one box online A. Complete line BB ifapplicabley ' <br /> A' New System D Replacement System ❑ TmatmeniM°Iding Tank Replacement Only ❑Other Modificntioo to Existing System(explain) <br /> B. 11 Permit Reacwal D Permit Revision ' Changeof Plumber 'Permit T...Rrto New List Previous Permit Number and Date Issued <br /> Before Espiname Owner <br /> _ IV.Tv eof POWTSSvstem/Com ooent/Device: Check all that apply) <br /> Non-Puessndzed le-G,ound D Pres.nnized ht-Cronnd ' Ar-Grade ' Ward>24 in,orsuitable soil 'Mound 424 is ofsuimble .it <br /> Holding Tank 'Other Dispersal Compo nen[(explain) 'Pretreamem Des ice(eplarr <br /> V.Dis er,m reatmeIn Area Information: <br /> Desna Flmv Bvd) Dsig.Smi Application R.te(gpdst) Dispersal Area Requ' d(st) Dkeresal Area Pzopreed(sq System Elevatlon <br /> 1ST eco ( Asir .?boo <br /> VI.laoklnfo Capaoity in ;Gall.r, <br /> tal 4of Manufactu <br /> Gallons Unit _ <br /> N—tanks Existing Tanks 2AL - <br /> U - V C- <br /> SepticarHold,rel-k <br /> a <br /> LIDsing(Ni <br /> I'll.NesponsibibD Statement- 1,the undrrsi,gned,assume resp... lit.rnr I.atailarhm of the PONN TS hum.on the attached plans, <br /> Plumber's Name(Print) PI u bine iZ <br /> MPMPRS Number Business Phone Number <br /> I t Sorer �Pp� / d:?U-7 7/j' '17,) 13s <br /> Plumber s A ss(Succi,Ciry,state,Zip Cade) / <br /> i / c - <br /> VITT.County/De artment Use Out y <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuina Arent Signature <br /> ❑Owner Gnen Reason for Denial <br /> S 37S.0 5%/3-/el 6-�. 44,.- <br /> IX.Con ditions of A pp roval/Reaso as for D isapproval D p D <br /> MAY 12 2014 <br /> Auu[n roaomplcte rlum mane s>ztcm and sunmlu.tne Cou aotr on oarernm lou @aabvv Hi.,maiplY�tETfCN'-`- <br /> D ZONING <br /> SBD-6398(R. 11/11) <br />