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canwnweeml.gov Safely and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 vm C f- <br /> sADn Madison,WI 53707-7162 Sanitary Permit Number(b be filled m by Co.) <br /> VV ■ ■ szi��3 <br /> Sanitary Permit Application State Tnmaction Number <br /> In accordance with s.Comm.61.21(24 Wu.Adm.Code,evbmiuioo ofPois fum b the apgopv0e gwemomhi <br /> -� <br /> and u rcgrmcd prior b obtaining a sandmy person. Note: Application forms for state-owned POWfS an: Pmjcd Address(if diB'real than mailing address) <br /> submdted to do Deparlmam of Commerce Personal infomat m you provide may be used for secondary <br /> pusposcs in accordance with ie Privacy Law a.15. 1 m Stan. p <br /> L Application lnfasratim-Plow Print AB Information 9/04 1 CouM4` Rd 1) <br /> Property 0wuer's Name Pmml# ant. 3433 0/1000 <br /> �sdr prtcK50M ) -0/4-1.39.17- 33-2 01-000- <br /> Property Owner's Mailing Address Pfoperry Locairon V.1.30 A49&5 >F fht <br /> 9/04/ a"n-<Y foow <br /> d -'D Cwt Lot <br /> city,State zip Code Phone Number NE Y, NWY, Section 33 <br /> Web56er I.VI 5cF893 (715) 349 -84.08 T39N; R/�'erw <br /> IL Type of Building(dkm k aB that apply) Let# <br /> ❑1 or 2 Family Dwelling-Nmnbw of Bodrooms Subdivision Name <br /> Block# <br /> ❑PobliclCommercul-Descabe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> W Townof -/AlCOLA <br /> III.Type of Permit: (Cho&only,ease box on line A. Compleie line B if applicable) <br /> A- ❑New Sysbm Replae®eel Syefem ❑Tremm-taoldmg Task Raplacancut Only ❑Odw Modification to Existing System(explain) <br /> B. ❑Perms Ronewai ❑Permit Revision ❑Cbange of tanber ❑Permit Transfer b New List P ,cus Pemrt N®ber and Date Issued <br /> Befere Expiration Owner <br /> IV.Tyw of POW" Ca. VDevioe: iCAedl a0 tlmt■ <br /> ff Noa-Rassmized in-C o ❑Aessmized InGrouod ❑At-Cade ❑Mound>2d is of suitable sail ❑Momd<z4 ia.of suitable.fl <br /> ❑Bolding Talk ❑Other D.WW Cosgraomt(expI.) ❑RcercatmatDevice(esplam) <br /> V reatmeot Area hrformatlon: <br /> Demga Flow(gpd) Design Sod Apphcabon RaWgp6f) Dispersal Arca Required(aB Dispersal Area Proposed(e) System Elevation <br /> '450 o.7 &443 m Fr (050 97.0v <br /> VL Tank Indo Capadly in Tow #of Mamfadrer <br /> Cragom Ga6ons Unit so v <br /> NmrTdn Hxinmg Tanb <br /> �`C er lbldug Tank /ono — /000 1 C..LY M t G. , <br /> Dosing chunber <br /> VII.Responsibility Statement-4 de undersigned,asses resMosibifity fa isstalladoa of the POWTB sbowu on the attached plans. <br /> Phnba's Name(Print) Phmnber's Signature MP/hWRS Number Business Phone Number <br /> 6OAde RoFStiolwt 1 6,-)A4 12z7lo9/ 349 - 7zBlo <br /> Phrmber's Addams(Stoset Cllr,Stab,zip Cade) <br /> OoX s/ Sirek/ <br /> VIIL L,2EqTMwbcnt Use Orib <br /> Approved ❑Disapproved %udFw Dasolasual Issuing <br /> ❑Owner Crivon Be—for Doing S'5 23 44Itch d/ <br /> Tx.Conditions ofApproraVReaaomfor D6 nrtrval <br /> Anal`anpW ptarfarshe yahs mA Is The Carly any as papr not Imthm8 to x1ads In ate <br /> SBD-6399(R.02(09)Valid tlw 02/11 <br />