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P County
<br /> Safety and Buildings Division
<br /> 201 W. Washington Ave
<br /> }iO P_O- Box 7162 Smuom,Peron Nmnner(to be nueJ in by Co l
<br /> P p r. Madisfa WI 53707-7162
<br /> ari
<br /> Sanitary permit Application m'D°" `"°""ambo` n�
<br /> In accordance sveh SPS 39)11(2).Wit.Adm.Code,submission of this form ro rhe appopriem governmental unit 0C
<br /> is required prim to obtaining a sanitary peemir. Noce:Application farms for sone-ooned POVi are submluee To Po'ccr Address(it difterennfor,m -line address)
<br /> the Dep ,nett of SePory and Professional Sennes Personal information you provide may be used fa seeoMary J 8'
<br /> ,mi incorJance with the Pi I.aw,s. t5 OJtl Nm,Stet,. W)SIJ 2rt✓ef Nf RJ
<br /> I. A P,Iaa u t i nn Infnrnm loan-fight,Print All Infnnnmino p
<br /> Property Owner's Name �.L Pnred e
<br /> l4r/s� mo�llr� �� 38 al�ola-� -Is-Odli-a/-C a
<br /> Prop,,,0,,a,'I Mmlmg nearest
<br /> C 7072f
<br /> &>,®CI'mPeny Locmian IsE"JG
<br /> SaC• a,
<br /> City,State Zip Cod, Phone Number y,, '/., Section I
<br /> 06 n br. LV X__ Q feircleone)
<br /> IL y pc of Ruildirri...k tall that apply) ,J I.atd , f�N,
<br /> �fllor?Family Dwelling-Number oFBcdmoms -/ -1 Subdivision Name
<br /> Block IT
<br /> ❑YublielCommerdal-Descni,c Use
<br /> ❑ CIry of
<br /> ❑Stam Oswed-Describe Use CSM Number ❑ Village of
<br /> Vr , � QI r°wnnr Jo_o/lsrr .�
<br /> 111.'I'cp,of Permit: (Check only one hoc on lined. Complete line B if eppliaable)
<br /> A. Newsyttnn ❑ Replammvm System ❑TreatmaNuolafng Tank Replxem,m Only ❑ ocher Modiacminn toExistin S tom
<br /> g.Y (explain)
<br /> B. ❑ 1§rmo Rmi ❑ Permit Reysinn ❑Change.1 Plumber ❑Permit Transfer m New Lar Revimu Peron Numb,rand Date hsued
<br /> Poore F..cpimnion Oenv
<br /> I\'.'I'.beof TO1s''lS S.etem/Comnm enl/fleciee: Check nil that, rk)
<br /> CYNan-Pon,co,ec!ln-Ground ❑ Pressurized ln-Grourvl ❑At-Garde ❑ Moam1>'_1 in .1 soi had,mil ❑Ni and 124 inofsuirable mil
<br /> ❑ Holding'Tank ❑Other Dispersal Companem(axplaim ❑Yretmmmem D,vlce(,plain)
<br /> l'. Dis ueal/ tea lmatl Area Information:
<br /> Design Flosv Will Desicn Soil Application Rate(epdst) His rI Area Required(star Dispersal Area Proposed(a) System Elevation
<br /> 600 , 7 8G'/ 9k- 9/.9
<br /> \'I.Tank Info Capacity in 'Poral qof Manufau er
<br /> Gallon Onlions Unts
<br /> New Tanks Eistink Toil, 3 ; `;
<br /> e`/U
<br /> or
<br /> scL V'
<br /> gaan, lank .�O W-0 f�Lfr✓ ^ I
<br /> Dosing Chsnb°r 7SD 1,7"O r t jC
<br /> \'II.Hmpnos filit, Sm¢ntenr1.rhennJersigned,rkmiv reepmsihitiry for intiall:uion of One POWTSshas on he auu,h,d plans.
<br /> Plumber i Name(Pring Plumber's Sinmure AIPpIPRa Number Business Pnane Numbe:
<br /> ,a le d, �f rel / �� dJsBS A 7iS-AGG- 4/r7
<br /> Plumber',Address(Street.City.State.zip Cad)
<br /> _) 774; L7 ;fi 3 � weds/., w1 S�+as3
<br /> \''l1.Ci mcllle artmem U'zuA in—rd El only
<br /> Penn Fee Dore issue) Issuingh,(ent Siunwnre
<br /> S
<br /> LIOwner Given Reason for Dermal
<br /> IS.Conditions of.\pproca llRenums for Disapproval
<br /> Adam m,onrrtne Tom,for me narem:rnn mnmo m me County Antl oo raps mo n„ik n s tae.I t inrne,too,
<br /> SBD6398(it. 11/11)
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