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cOmmOrce.w1mov SaJ sty and Buildings Division <br /> 201 W. ashin County <br /> isconsin 8lonAve.,7-7 62x7162 -t� <br /> Madigan,W[ 53707-7162 err^ e <br /> �Nrine t Of Curraareree Sanitary annit Number(to be filled in by Co.) <br /> +3g <br /> Sanitary Permit App ieation Starer aetion Number <br /> In accordance with S.Comm,83.21(2),Wu.Adm Code,submission of form m the a <br /> s�tbmIIted Department of prior m obtammg a sanitary permit. Note: Applica'an Forma fore teowaWgovemmental <br /> cordance with the Priv mmerce. Paeoml information u provide may be used fors secondWTS ary Project dress(if different than mailing address) <br /> see in ac Law,e.15. 1 m,Sfffi. <br /> I. A liation Wormanum_Please '1l t- <br /> Property Owner's Name Print All Intorination p,�' � FOS 6"a,n /'2d <br /> we Ile.^ <br /> Property OWner's Mailing Address 3) t'yIC Parcel# <br /> I `J OAA - 4131r -O3S�00 <br /> // del flunopeq tion <br /> City,Stam Zip Cock Phone Number Govt Lot td <br /> AA5Rv- M^/ SS NwY .7W Ys Section J� <br /> IL Type of 9Sst - 4140e- ?6•y-d j (circle onew)c <br /> Building(check all flat apply) Lot# T-�—I N; R �/✓ le an <br /> �lor2 Family DwelEag-Number of Bedrooms r( <br /> 3 Subdivision Name <br /> ❑Pubhe/Commercial-Describe Uee Block# ( <br /> 0 <br /> ❑StamOwned-Describe Use CSM Nu ❑City of <br /> I <br /> mber ❑Villa <br /> 06.3�j t�9q'! ge of <br /> CENX.r&TA g10 Town of OA&A,4 <br /> IIL Type of Permit: (Check Only am box online A. Com tete ✓vI /l G.SA4 <br /> A. P e B if applicable) <br /> . New System ❑Replacement System ❑T <br /> reamtertoldiug Tank Replacmreot Only ❑Other Mo '[cation to <br /> Existing Syataa(explain) <br /> B. ❑PemtitRenewal ❑ <br /> Permit Revaioa ❑Change of under ❑ Lint Previous <br /> Before Expaatiw Permit Transfer m New it Number and Date Issued <br /> IV.T of POWTSOwner <br /> 21 tMICom mVEk-,ice: Check an tha a <br /> -Pressuri <br /> Non In-Ground ❑pressurized Io- <br /> ❑Hol Groin 11 At-Cd. [I and>24 im of suitable soil ❑Mound< <br /> ding Tank ❑Other Drapenal Compaent(exphm) in.of suitable Boil <br /> V. aVrreatotett Ara Wormatltm: ❑Pretreatment Device(explain) <br /> Desi n o O d) Design Soil Application Ra Required <br /> idepdsf) Dupenal <br /> 7 (� Dr'1'proposed(80 System Elevation <br /> VL Tank Wo 40 5 97' }3 <br /> Capacity m <br /> To #of <br /> Gallon GallVail, Ma°Ofactruer <br /> New T,*, �6 Tse 0 8 <br /> Septic w Holding Tank ee O O rn 'w U 2C <br /> Dosiog Clamber <br /> X <br /> igly <br /> VII• w'spott9(Print) <br /> Statemat-L the undersigned,assume responsibil for installation of the POWTS shown a the attached p <br /> Plumber's Name(Print) <br /> Plumber's Signature Ons. <br /> ✓�/ <br /> e-le- fAe, IG /H J I7- / /1 Aar MP/MFRS Number 1 Bunions Phone Number <br /> Plumber's Address(street,City,state,Zip Cade) e" yrlC /-"-_ atnd <br /> 7 <br /> 776 �e6s�e✓ L✓� Sy F/93 <br /> , <br /> IL Cour /De artment Use <br /> Approved ❑Disapproved Permit Fee Date Issued <br /> Inn' Sigmture <br /> ❑Owner Given Reason for Denial S „Ds� <br /> IIG AConditions Of /�J f1lMit <br /> NEkI OW6c(.IUG "Ira .8E _ <br /> i Fdd7- Fto� '5aL Ad 5 F �, PC ?wK F <br /> Sae�lvw cac. <br /> Arorhtosa.*Uplans for,meayalem Wwhadsm <br /> Coanly only an paper not ka than a in x 11 tsehes in s <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />