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cornmerce.Wl.9ov Sa tell a lid l lu i ldi ups I)i c i s ion C.un1 <br /> 201 W. Washington Ave.. 1'.U. Rus 7162 zG/"sN <br /> ��f iscons i n Madison,Wl 53707 7162 Sanitary Permit <br /> /it Number(to be filled in by('I),) <br /> Oapartment of Corra, 4 / 9 <br /> Sanitary Permit Application State'Irna.acion Nuoll,c(, --- � <br /> In accordance wide s.Comm.83.21(2),Wis. Admsio <br /> .Code,submisn of Illi.,form pr <br /> Io IIIc apopriate n <br /> gowvulantaed.l 5,2 __ , <br /> unit is required prior to obtaining a sanitary permit. Not, Applicalion loon, lie slant-owned PO\\"fS arc Project Address(if dillcrenl than mailing address) l) 1 <br /> submitted. to the Department of Commerce. Personal information you provide may be axed door secondary <br /> purposes in accordance with the Privacy law,s. 15.04(1)(m),Stat,. Il JI <br /> 1. Application Information—Please Print All information _ <br /> Isropc y Owner',N,1 Parcel G <br /> property(honer i Mailing AJJrcwx property I,ocalian <br /> —�---- <br /> "/3 RC _ Lot <br /> City,Slate Zip Cade Phone Number - Section <br /> �v N -� 5-"IS'7•7— <br /> qry (circle one <br /> 11.Type of Building(check all that apply) Lot a <br /> Xnr2 Family Dwelling-Numberof Rct1rooms �'- Subdivision Nene ---�— <br /> Block h <br /> Public/Commercial-Describe Ilse <br /> _-- <br /> _ ❑ City nl'_ _. . <br /> ❑Stale Owned- Duscribe(Isc CShl Numhcr ❑ Villagcor / <br /> gown or4A)14-- <br /> 111.'Type of Permit: (Chink only one box on line A. Complete line ll if applicabic) — <br /> a <br /> ❑ New System placement System ❑ 'I'rcatncii0lolding l ank Replacement Only ❑ OWer Modification to Existing Symon(,,xpla int <br /> Il. ❑ 1'ernil Renewal ❑ Permit Revision ❑ ('hang,,ol'Plund•cr ❑11.,oil'Igoe hr to Neu List Previous permit Number and Dale Issued ---- <br /> Bcfnre Expiration Owner <br /> IV.Type of PO\V'1'S S stem/Com nnenUUa vier. Check all that:u u Iv) <br /> ❑ Non-Pressurized In-Grund ❑ R'cssurized In-Ground. ❑ :\I-Omdo ❑ Mound_2d.in.of,uitahlc soil Mound 24 in.ofvuilnblesuil <br /> ❑ <br /> 6 P P I 1 _. ❑ }cVcalnsnl Device(explain)]lolrlin 'Tank ❑Other Dispersal Component Hain(eN <br /> V. Dix ersalf1'reatinent Arra Information: <br /> Design Plow(gpd) Design Sail plication Iiale(gpdaQ IJispuxal:\Ica IteyuireJ(sl) Dispersal Area PmposeJ(sQ .l'yslem Elocalion --_-- <br /> so ysa yso <br /> VI.Tunk InGI Capacity in '1'aL'11 rl of Manulacturc, --- <br /> Ciallons Daltons Unita ° <br /> NL.lahs i,iing'I':mks <br /> 0 <br /> � V N � in LLV 0. <br /> Septic or Modelo a.k 73 4 73 0 _4 15-06 o� /r c-I <br /> Dosing Clem Mar :5-i:5 () __ —5-CID T� - <br /> V1 1. Responsibility Statement- 1,the undersigned,assume respousibilih'for inslallali an or the 1•ol\"1'S shown on the allachctl plans. <br /> Plumbers Name(Print) Plumher's Sign:ncc M1IPiMPRS Numhcr I)usincss Phone Number <br /> AJA-d ie— Rufs�o /rl � -/y � -- -zz76 q� Y� 786 _ <br /> Plumber's Address(Street.City,Slate,Zip Codc) <br /> Orr S�y. f/`Gti) LJ.� SY87� <br /> Vill.Cour /Dr artment Use Ooh' ------- -- <br /> 1'cnnd fi. Dale hsucd hxuinG: S n tgnalurc <br /> Approved ❑ Disapproved —r <br /> ElOwner(liven Ituasnn for Deni;d S 300" I� O I —_ <br /> IX.Conditions of Approval/Reasons for Disapproval -- <br /> Much to complete plans for the system and wlxnit la tiv County only all tso,r nal Ifo Ihm.a 16[r I Ind..In site - <br /> SBD-6398(R.01,07)Valid Ilan 01,09 <br />