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` Safety and Buildings Division County R <br /> � <br /> W. Washington Ave.,P.O.Box 7162 V`r ' <br /> scons% Z01 W <br /> in Madison,WI $3707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Senator Permit Number <br /> In accord with Comm 93.21.Wu.Adm.Code,personal information you provide ❑ Check if Revision <br /> ma be use for sew s Pmae Law, 15. IR <br /> 1. Application Information+Please Print All Inmformation Stam Plan LD.Number <br /> Property Owner's Name Parol Number <br /> aiK o- YI/0 ^1-c- i✓i 1el'e ala -</23� pa-7a( <br /> Property Owner,Mailing Add,,. <br /> 11 Property lacaorn � <br /> 1l 1,5- e14 Yl70y va.e A-,c- W_ YSr^rf <br /> A:S �'ZT 1'0 N,P, S <br /> City,Sam / zip Code Pham Numbe, Lm i tuber Block Nombu <br /> V e' ,✓ U 1{ Gdl. 1 Z a 7 4571 syr -77 73 Subdivision Name CSM Number <br /> L/. 'I 5- <br /> 11.Type of Building(check11 that apply) 3 Dip <br /> m.lor 2 Pamlly Dwelling-Nu r of Bedrooms o,yV�Jlage / <br /> ❑PublkrCommercial-Describe Use rpaawmlll J r.Ks a�a <br /> ❑Sam Owncd Neaten Road <br /> Nalla(a,4 LGrrc Rad <br /> III.Type of Permit: (Check only one box on Me A(numbering scheme for internal use). Complete line B if applicable) <br /> A. FPr Cowry sue <br /> 1 New 2 (] Re <br /> epla evnt System 3 laument of 6 is Addition to <br /> 5 smm Tavk owl <br /> Existing System <br /> R. ❑ Check if SaNtary Pe t Previously Issued Perm)Wumber Dam Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> U JLNon-Pressurized imGrou� 2l❑ Mooed 47❑ Sand Filter 50❑ Comuucted W,daM <br /> 22❑ Pressudssd In-Gmun 4111 Holding Tan; 49❑ Single Pass 51 ❑Drip Lim <br /> 45❑ At-Grade 46❑Acrobie Trument Unit 49❑Reeitulaung 3013 Other <br /> V.Din ersaBTreatmml Are Information: <br /> Design now(gpd) Dispersal Arca Dispersal Area Soo Application Percolnion Rate Sysmm Ekvaaion Final Gnde <br /> Required Pmpond Ram(Gak.IDaynSq.F,.) (Min./Inch) Elevarion <br /> oro q �� �j Yo 9a 5 <br /> VI.Tards Info Ca it,N Total Number Manufacture Prefab Site Stcd Fiber Plastic <br /> Calot GNIOm o(Tanks Concrete Comrne, Glass <br /> N,w I Eaudry <br /> nnk, TN, <br /> $iplleor HPldlne Took to OO - IOdp le )e / <br /> omina CWmbe, <br /> VII. Responsibilit Stetem< t- f,the undradillstel,assume resPomlbWTy for installation of the POWTS shown an The attached plans. <br /> P bet's Name(Print) Plumbe Sig re /MPRs Numbcr Business Ph..Number <br /> A e3✓fe` r380FT lis. 5—,t0 Soo <br /> Plumber's Address(Strut,City.Sum.Zip Code) <br /> �s w aes" C K Ott s oo-cr L/r 5-Lrg�( <br /> VIII Count /De anmenl se Onl <br /> Approved ❑ Disapprove Sanitary Permit Fee(includes Grotodwwer Date Issued Issuing a Signature( reps) <br /> Surdargc kq <br /> Owmr GivnWrial Adverse 1l 150 rp I71,Y01 <br /> Deennbarion' `� �Jl/ �q <br /> IX. Conditions o[ApprovalfReason,for Disapproval <br /> Much romPlul Prem Ire the Caunry eettl ter the tree.on wwr net Ina thin 31,2,11 inrhn nt or, <br /> SBD-6398 (R. 05101) <br />