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county yG� <br /> Safely and Buildings Division <br /> �g 10s .)�I 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co) <br /> I' pS Madison,WI 53707-7162 w <br /> ' :j 5(oG 8G O <br /> Od <br /> Sanitary Permit Application Nm SudeeTransactiourN``um,b//e,�J _ <br /> In accoanwith SPS 3832112),Wis.Adm.Coda o,submissioncitdIntel to the appropriate governmental unit 2,? 5542 <br /> is required prior to obtaining a sanitary Permit. Note:Application tomos for state-owmcd POW'I S are submitted to Project Address(if different than mailing addoess) <br /> the Dclumment of Safety and Professional Servies. Personal information you provide may be aid for scwndary / <br /> purposes in accordance with the Privacylaw,s. 15 04 I m,Stals. 2& Old 35 <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Provilq Ag6Y:010.374$ro2-(epp <br /> Property Owner's Meiling Addms Property I.ocatom <br /> 'z 6 v SG o/� 3 Govt,tot <br /> city.Store- / %ip Cde Phone Number Cti 'A, S_c.l 'A, Section <br /> � : �J�el'!cre <br /> a <br /> NR_ <br /> B.Type of Building(check all that apply) Wt a <br /> IlN or 2 Family Dwelling-Number of Bedra+ms Subdivision Name <br /> Block q <br /> UPublic/Commercial-Describe Use �— — _--. <br /> — ❑GlY of <br /> ❑State Owned-Describe Use CSM Number ❑ village.1 <br /> - Town el /y/e Z/✓Cl•'l� <br /> 111.Type of Permit: (Check only one bon on line A. Complete line B if applica Me) <br /> A. ❑New System Rcplazemcm System ❑TrcammnUllodinglard,Replacement Only ❑Other Modifieatiorm Existing Sy'srem(explain) <br /> R. ❑ Permit Renewal U Permit Revision UChangcof Plumber ❑Pentralranslerm New knr Previous Permit Number and Dam lemd <br /> name lispimtiml Owner <br /> IV.Type of POWTS 5 stem/Com anent/Device: Check all that apply) <br /> U Non-Pressirmcd 1.-Ground UPmssuriril In-Ground U .At{;rade 401kMound>24 in.ofsmoblemil U Mound<74 in,ofsuilnhle soil <br /> ❑ holding Tank ❑ONer Dispersal Componwt(esploin) UPmociumma Device(enplmn) <br /> V.Die ersa Vfrealmenl Area Information: <br /> Pesign Flow(gpd) Uesign Soil APPlicytmir Ratggpds0 Dispersal Arca Required(s0 Dispersal C.Proposed(s0 Systun Elevation <br /> 3c'(') / 3e' 4i 1 -7 C":) i 78: 3 <br /> V1.T'ank Info Capacity in Inial ilof .Manufacturer <br /> Gallons Gallon Unit. n C V o <br /> New Tanks Exminy Tanks <br /> Scone er.,_a. �- 7J O jjo �.� <br /> lion,Glxonkr 7�C� 7,C' /n G <br /> VII. Responsibility Statement- I,the Undersigned,assume responslblllly for installation of the POWTS shown on rhe auachd plans <br /> Number's Name(Pont) Plumber' Signamry / MPIMI.Numher Business Phone Number <br /> WAD17 RUFSROW / //V 227691 715-1494286 <br /> aC�4� <br /> Plumber's Address(Street,City,Statq Zip Code) <br /> In BOX 514,SIREN,WI 54872 <br /> Vlll.Count /Dc artment fisc Only <br /> U Approved El Disapproved 1,)ermit Feu Dal,Issued Isaia,A M gnatum <br /> 7s32 z7�A+e )3 <br /> ❑Ownm Given Rearm fur Denial <br /> IX.Conditions of Approval/llimsons for Disapproval <br /> Murb to ve.,korphm far rbc r)staa aM wbmil to rbc Coanlr only on paper nm loss Ibsn a In r 11 irri in sine <br />