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N urv.-rat Courtly <br /> Safety and Buildings Division U/�N / <br /> 201 W.Washington Ave.,P.O.Boz 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison.WI 53707-7162 W <br /> Sanitary Permit Application bore Tr p//io//n Numb r <br /> Inoccordance with SPS 383?I(2),Wis.Adm.Code,submission of this form tote appropriate piemmenml unit �'/ tCux� <br /> is required prior to obtaining a sanitary permit. Note:Application to.for slaw-mvnN PO WTS suc submim d to Project Address(if different thanf^�line add e ) <br /> the Ikpartmem of Safety wd Professional Sanies. Personal infmmimion you provide may be used for semndry' 3 7 ya A��ry r•� G Z 1,7 <br /> u oses in rcordan<e with the&iwc Lmv s.IS 04 1 m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Oona',Name Parcetq 07.0/fiZ <br /> P41- /nor oZ)srO o2 V40") <br /> Pmpcny Come,'',Mailing Ad/dress t - Property location def <br /> 6/-ZRS/7 er/I71+J ci/`C.IE'. GooL Far 5 <br /> City,bele Lip Code Phone Number y,, G, Secfion -7 <br /> E-d1"'jQ I /n NI, SS ?/ (circleonc <br /> IL'1'ype of Building(check all that apply) � I'm# <br /> FA I or 2 Family Dwelling-Number of Bedrooms Sabath, merName <br /> — <br /> block# <br /> D PublielCmummusl-Describe Use �- ❑Cityof <br /> ❑State Caned-Describe Use CSNI Number Dseillagcof - <br /> V/0/0q JsTman of V^r <br /> Ill.'1'ype of Permit: (Check only one box on line A. Complete line B if applicable) QIQ—14-J3 <br /> 70-4-32 o— <br /> A 11 Ne" cdonamord System D TreatmenVHoding Tani:Replacement Only 11 Other Modification m Gxisfin_System(explain) <br /> Is. [IPefmlt Rencwvl D Permit Revision D Changeof Plumber ❑Per mit TrwsdnONew List Previous-�Permit Number and Data Issued <br /> Before fixpimtion Owner /Q 9-SI '5_1D_gq <br /> W.Type at PO\\'TS System/Componenl/Device. (Cheek all that appl-) - <br /> ❑Non-Pressurized la-Ground DPressurized In-Ground 11At-Grade Dnlound>24 in.of suitable suit nlound<2Jin.mfsubablc soil <br /> P,folding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> \'.Dis ersallT'reatmeor Area Information: <br /> IMign Flom o,pd) Iksign Soil Application Rateb pdst) Dispersal Area Rc,,mmd(so Dispersal Area Proposed(sp System Elevation <br /> qS d I I -- <br /> VL'1'aaklot. Capacity in Total #of Merame'Turer <br /> Gallons Gallons Units <br /> New Tanks F.'ro.8'reM. - <br /> � U C O C <br /> Se,siasr Holding Tank 3304 r� �Gr+j _2 <br /> umm,Chamber <br /> \'11. Responsibilitc Statement- I,the underetoned,assume responsibility for insularism of the PONVI S shorn no the attached au, <br /> Ylumbn's Namc(Print) Plumber's Sigmturc AIPIAIPRti Number Business Phone Number <br /> Plumbers Address(Street,Cin,State,Zip Codi) <br /> N' IL CounWoe irtment Use Ontr <br /> Approved ❑ Disapproved Petmgir Fce Date IssucJ q Issuing - m -zrtatun <br /> ❑ Daher G"'m Rvasmn Ior Denial s t.J7Jr �la�is /3 <br /> 1Y.Conditions of Ld p1plroyal/Iicasans for Disappruxal MCOUNTY <br /> Mitis Np ,$Ylld61e. df[2 BUY r7 Sorb At�ClPvsf's LP.l1 I$ d(/Jll�ld�p�j� � <br /> SiEe Is yr_G Irytloadwt -b be.in-41e FI/w6( Qat: of lJnreh Send Ae1td.' L/Sil AIJ IttAr"cuesauuchmcumplete Pt,n,mrmu;st.m and sunmumme enumy maty nn taperum le:.mnatasummes In <br /> SBD-6398(R. I I/11) . <br />