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^'rw's - Coum <br /> Safety and Buildings Division <br /> 201 W.Washington Ave.,P.O. Box 7162 Sanimry Permit Number(m he fill[•d in by co.) <br /> Sp Si Madison,WI 63707-7162 f06 SbS <br /> ,£� S w <br /> Sanitary Permit Application gone,T'a 'hnN"pm16 ` <br /> In accordance with SPS 383.21(2). Wo. Adm. Code, submission of Nis form or the rime overrunenml <br /> suite <br /> o Y <br /> unit is ed to the prior to "braining t sanitary permit. Note: Application fonts for yen provide <br /> POV be are Project Address(if different Nan mailing address) <br /> bar ax ed m IM Department of Safety idi ffic Purace Sen'ics. Personal information inn you pnrviJe may h used <br /> fur Applicat.instairyion <br /> purposes it aeon-Pl win,IPr Print <br /> All'Info s. 15Af(gpn).Sats. <br /> 1. A licatiun bdnrmatinn-Please Yrint All Information co =17OO <br /> Property 0.'near's Native / Parcel p <br /> e.eel r 5} X t.I O <br /> ropeny Owners YU iling Address Property Location <br /> N� G—, Lnt /6 <br /> City.Slate Zip Code Phone Number E I q,S�s Soction <br /> 1 (d,de r}� ) <br /> 11.Type of Building(check all that apply) Lm p T N; R_Lf_—E oru6d <br /> ❑ 1 or 2 Family Dwelling-NumRr of Bedrooms Subdivision Name <br /> I Rueeka <br /> mm/com:nerel:u—Describe axe f G ` ❑ citY of <br /> ❑Stem Owned-Describe Use CSM Number q❑ .v,,illage of <br /> V[own of <br /> III.Type of Permit: (Check ulY one box on line A. Complete line R if applicable) <br /> A. ew System ❑ Replacement Syxrem ❑ Tremme n/D"Iding Tank to lavement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New, List Previous Permit Natalie,and Date knexl <br /> Before Expiration Plumber Owner <br /> IV.Tvw of POWTS System/Com neat/Devine. (Cheek all that apply) <br /> Nun-Pressurom In-Gmutal rasutizo,In-Gnmld 11 At Grace 11 Mutual! > 24 in.of,uiri soil ❑ Mouton! < 24 in.of stumble soil <br /> ❑ Bolding Tank ❑Other D'mxrsal Component(explain) ❑Po neutmem Device(explain) <br /> V. Dis rsal/Trealcalm Area Information: <br /> Dea'•I�IPlow(gpJ) Design Suil Applkvtion Rate(gpda) Dispersal Arca painted(sl) Dupersal Area Proposed isp System Elevation <br /> 1s a � � a3� ;� 7 <br /> VI.'I'nick Info Capacity in 'ruralp nt Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Iineaiag Tanks — J t; — <br /> 4Pri[nr <br /> WSinY ClIuIun1:Jhinr <br /> 7 <br /> 175o <br /> VIL ReaWnsibilib'Statement- 1,the undersigned,assume r punsibWly for' lunation of the PPM 'shown on the mmdted plans. <br /> Plot s Kane(Priv p Plumber x Sig wre }1 IMPRS Number business Phone Number <br /> Plot <br /> v (c, L, <br /> Plumlmr's Address(Stan . City,Stale,'lip Code) <br /> L 2 r� 1`3S$ <br /> V IL Counh/De are, t Ilse Onk <br /> pprov,d ❑ Disapproved Permit Feed, Dnto1, [,auto I e <br /> ❑ De <br /> Y � <br /> Owner Given Reason for nul 3Z-� <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> JUN 2 S 2013 <br /> Aua[h to rnmylete Vtam cur ih[ssnem and submi ui the Cuu ...h.up,ye.m,l less theta tat' aNG <br /> SBD-6398 SBD-6398(R. 11/11) <br />