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Conwerce.Wl.gOv Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 4p v o e <br /> yf i sero n s i n Madison.W1 53707-7162 SanitaryP it Number(to be filled in by Co.) <br /> Paparbusarst of Cenarreroe 4 5'�O <br /> Sanitary Permit Application State Trema tion Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm Code,submission of this form to she appropriate governmental 144) <br /> unit is required prior to obtaining a sanitary permit Note: Application loom for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 93700 <br /> proposes in accordance with the Privacy Law,s.15. 1 m,Stab. <br /> L Application Wormation-Plesse Print All Information <br /> Property Owner's Name Parcel# <br /> Jatin (redo ti 0/6 -3q)-j 61 400 <br /> Property Owner's Mailing Address Ition <br /> z3ex / / cons.Lot <br /> City,State Zip Code Phone Number Y., S Y, Section <br /> It <br /> S5-<,ti4 /41/41 X5073 dprl- r/7P-of/ SZ/ T 34 ; R [7 cm EQVIC <br /> IL Type of Building(dwelt all that apply) Lot# <br /> I or 2 Family Dwelling-Number ofBedroome 3 Subdivision I 4asse <br /> �y Black# <br /> W Pnbtie/Commeoial-Describer Use e,Am f 6004A al ❑City of <br /> ❑State Owned-Describe Use CSMNumbv ❑village o <br /> 2 Town of el" e/rl <br /> IIl.Type of Permit (Check only one box on tine A. Complete line B if applicable) <br /> A. <br /> New System ❑Replacement System ❑TreatmenuHoWing Tank Replacement Only ❑ Other Mo,lificabon to Existing Syden(explain) <br /> B. ❑PermhtRwwal ❑Permit Revision ❑ ChangeofPlumber ❑PermitTramferm New List Previous,PamilNumber and Date issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S tem/Com onent/Device: Chedt all dust apply) <br /> .®Non-Pressurized I.-G.und ❑Prewurvsd In-Orouod ❑ AFGnde ❑Moond>2A in.of suitable soil ❑ Mored<yt in,ofsuitable soil <br /> ❑Holding Tank ❑Other Disposal Component(caplam) ❑Pretreatment Device(explain <br /> V.DispersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdet) Dispersal Area Required(at) Dispersal Area Proposed(al System Elevation <br /> /3S0 . 7 / 9s,! 9 /94141 FY- OD <br /> VL Tank Into Capacity in Total 'of <br /> Manufacturer <br /> GaBone Gagers Unita <br /> New Tanks Exsung Tanks <br /> ur � N W r7 G4 <br /> Septic or Holding Tank /a,Sea- /6 s,0 .185'0 .G�•i✓ <br /> Doamg Chamber <br /> VIL ResponsibEty Statement-t,the undersigned,assume respomibBBy for installation of the POWTS shown on thea ached plans <br /> Plumber's Name(Print) Plumber's Sigmhre // MP/MPRS Nu Business Phone Number <br /> /e- //{a /n-r / /� oZ.i.S�TS� 7/S- S6(r- 4/S7 <br /> Plumber's Address(Stied,City,State,Zip Code) <br /> ?6 W 3 s' websfe.- c wt" s�ts9 <br /> VIILCoun AM sartmentumOnly <br /> 0 Approved ❑Disapproved Pennitfee Date Issued Issuing turn <br /> s 250❑Owner Given Rescan forDenial Z ZL-V 67 <br /> LC.Conditions of ApprwaUReaaorn for Disapproval ,y/aA 7z*j is <br /> c�v G <br /> Atbehtoeaopide pbmfarthe sysns and srbaatsetin Canmyody an paper ad les than 81 a x 11 imb a in strs <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />