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co1T1111etC@.WI.gOV Safely and Buildings Division County <br /> 20l W.Washington Ave.,P.O.Box 7162 i3 K p p,��f f- <br /> i sen n s i n Madison,WI 53707-7162 Sanitary Penoit Number(b be filled iv by Co.) <br /> Departmem of Commerce 53,2,2/ cJ <br /> Sanitary Permit Application State Tnmaction NuQQmber <br /> Tn accordance wiW s.Comm.83,21(2),Wia.Adm.Code,submission of thio form m the appropriate governmental ��� f�(I��^^� <br /> unit is required prior to obtaining a sanitary permit. Note: AppEurion forma fa ata[erowned POWTS are project Addrwa(if di$'erent than mailing addraa) <br /> submitted m the Depatnnen[ of Commerce. Pasowl information you provide may be wed For secondary <br /> a in accordance with the Priv Law e.15. 1)m,Stata. � ��� <br /> I. A Bcstion Wormation-Pleax Print All Wormation � SaAf�t/[ Lwn e <br /> Property Owner's Name � pure18 <br /> Jati � ©d�/e ooa. 9aso - aa - 300 <br /> Property lhvner'e Mailing Addref��I Property Location <br /> 7d S OQ/C � GovL Lnt <br /> City,State Zip Code Phone Number <br /> ''// Y., Y., Section I <br /> /T A�.s o n tNS .S�/O/.b (o%? -. 5'f'/- 7 790 T .3 S N, R � (circ E orre) <br /> IL Type of Building(check all that aPP1Y) )) Lar# � °(� <br /> ®lor2Family Dwelling-Numbs ofHedrooma T � �� Subdivision ams <br /> Black# S <br /> ❑PublidCommemial-Deepibe Uae <br /> ❑City of <br /> ❑State Owned-Ducribe Use CSM Numbs ❑Village of <br /> Town of Ike we)/ <br /> IIL Type of Permit: (Qteck only one bo:on Ihte A. Complete line B if appliahle)� _ _ _ _I _ _ _ - <br /> A �New System ❑Replaeanent System ❑Treatment/Holdin Tank <br /> B Replacement Only ❑OWa Modification m Existing Systan(explain) <br /> H. Permit Renewal ❑PamitRwoion ❑ eofPlumba List Previow Pecmil Numbs Date hawed <br /> Clang ❑Permit Tzamfa to New <br /> Hefom Expiration Owner 2 / <br /> IV.T e of POWTS stem/Com anent/Device: Check aU that a 1 J r0 <br /> Noa-Prossurized In-Gromd ❑PraeuriuA In-Ground ❑ At-Grade ❑Mounds 24 in.of suitable sod ❑Momd<24 in.of suitable Boil <br /> ❑Holding Tank ❑Otho Dupensl Component(explain) ❑Prdrwhnent Device(explain) <br /> V. rsaVTreahnatt Area Wormatian: <br /> Daigo Flow(gpd) Daign Soil Application Ralc{gpdef) Dupensl Aru Required(at) D'upenal Area Proposed(af) System Elevation <br /> 300 , 7 4,19 yid 99, 6 <br /> VI.Tank Wo Capacity in Tohl #of Manufacmra <br /> GaEom Gallon Unita �� � <br /> New Tmks Easatirg Tmrks <br /> c <br /> �a <br /> �c3 y � � ig� � <br /> Sepne a kloNing Tmdc �� 7`� <br /> IJoarg Clamber SOD 00 <br /> VIL Respotlsi6ility Shhment-i,the undersigned,assume raponsib8ity for inrtalladon ofthe POWT3 shown ao the attached plans, <br /> Plmnba'e Name(Print) Rumba's Sigoamre MP/MPRS Number Hwmeea Phone Nmnba <br /> ��r-.aD Ne�l�i n J J?�...� f/ � o�asas l 7/S- 866— y,.r> <br /> Plumba'a Address(Sweet,City,State,Zip Code) <br /> X76 � ,/ .�� ��s{ems wS S1f853 <br /> VIIL Cocn /De arlment Dx Ont <br /> Approved ❑Disapproved Pamir Fee Date leeucd laau'vrg em Sigwture <br /> ❑Owns Give Rwon for Denial S Q�/ �� � � v <br /> IK Condilimu otAppraysUReasom for Disapproval <br /> ��n�al of ��-� �2Tm�t��� �O(os� ���3a ��a <br /> Attach b eospkte pian for the ryateu and suhwa mthe Caan/y only on papa not les tbao 812 s 11 iveha b aiu <br /> SBD5398(R.01/07)Valid thru Ol/09 <br />