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cornrnerco,wl.gov W <br /> uildings Division County /L <br /> 201 Wn Ave., P.O. Box 7162 ,�4t�7"� <br /> fi sconsinWI 53707-7162 Sanitary Permit Number(lo be filled in by Co) <br /> DepertmeM of Commerce <br /> Sanitary Permit Application ale Transaction Number W <br /> Iu accordance w ith s Comm 83 2112).W is. Adm.Cod,submission of this form to the appropriate governmental <br /> amt m required pnor to ohtmnmg a sanlwry perms. Note. Application forms for state-owned POWT.S are Project Add ress(if d i Bbrem than mail ing address) <br /> ,,hntied Io the Depanmeol of Commerce. Personat ,L,rmation you provide may he used for secondary / n <br /> purposes in accordance tush the Privacy Law,s. 15.04(1 Xm),Slats <br /> I. Application Information-Please Print All Information <br /> Propem Uwner-s Name Parcel N <br /> (2, 3a 1 1 / 0/0 :).-- coo <br /> 1, rem Ooner',Marling Address Property Location <br /> �! U Govt. Lot—L0 <br /> l m_51ale Zip Code Phone Number �,, �G_ Section <br /> circle one <br /> SS SSS 7in <br /> - I �{o N. R nr V� <br /> Type of Building( heck all that apply) <br /> Sulxlry iron NmI or 2 family Dwelling-Number of Bedrooms' JI- <br /> ! 1(✓�! VPubhvCummerciel-Describe fisc ❑ City of❑ Village of _ <br /> L'hate Owned- Ikxnbe(:,e ___.—_...._ ____ _._—_...____ <br /> T l'own of <br /> Vol i7 171 <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ❑ Replacement Svstem ❑ Treatment/l holding Tank Replacement Only 0 Other Modification to t:xisung Svstem(explain) <br /> it <br /> New System I <br /> ^—r-- —h- List Previous Permit Number and Date Issued <br /> B. ❑ Pcmi,t kencwal ❑ Permit Revision ❑ Change of Plumher 0 Perms I ransfer to New <br /> Before Fxpuamm Owner <br /> IN, Tv to of PO\4'TS Svstem/Com onent/Device: Check all that apply) <br /> f Non-Pressurized In-GrounJ 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 inof suitable soil 0 Mound<24 inof suitable soil <br /> Holdury Tank 0 Other Dispersal Component(eyplam) 0 Pretreatment Device(explain)__ _ <br /> \'. ----- <br /> DIS ersa UTreatment Area Information: <br /> Dc,an flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Arca Required(sQ Dispersal Area Proposed(sf) System Elevation <br /> 3� I , 7 �z � 9/ 33 <br /> \-1. Tank Info Capacity in Total N of Manufacturer e J <br /> Gallons Gallons Units Y <br /> tic. Tanks Psaimg banks u p v w <br /> repo :r Hoidmg Im:k 7 <br /> Do ing Cha one, <br /> I <br /> \ <br /> 11. Responsibility Statement- L the undersigned, ssume responsibility for installation of the POW'I:S shown on the attached plans. <br /> Plum R'r s',a nm,Pant) Plum cr s Signature MP/M PRS Number Businex Phone Number <br /> Plumber , Addrees(Sneel C m.S tate.Lip Code) / (� Q� <br /> P � V �Cd e4 �r W/rr S 1 / <br /> I VIII. Count y/De artment Use On v <br /> Permit Pee <br /> 0 Date Issued Issuing gens Signature <br /> 'x PDro'ed DlserOicd S a <br /> I' El Ownner s en Reason tirt DenialW <br /> IX. Conditions of Approval/Reasons for Disapproval n <br /> u MAY 2 4-2007 <br /> '— WaN w aunplrtr plan.for tM1c.9 strm end eubmit m the Count}onlYna apenIythan N RNET COVNT / <br /> ZONING <br />