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Salcty <br /> COMMI? ce.wl.gov 201 W.ctdi sod,Buildings Division <br /> . . .Cama <br /> /� 6 Box 7162 y r10 Pel <br /> sco. 53707 7162 Sanitary Permit Nuntbcr(to be filled m by(n.) <br /> Dopartment of Commerce - - 521177 <br /> Sanitary Permit Application Slate'CransactimtNmuhcr <br /> In aearrdmtco with s.Comm.83.21(2),Wis.Adm.Code,submission of this Tann to the'apprapri;ue governmental <br /> unit is required prior to obtaining a sanitmy permit. Notc: .Application forms for state-owned POWTS arc Pro)cet Address(irdifferentthan mailingoddrass) <br /> submitted to the Dcpanmmin or Cununcrcc Personal inlmm rbor you provide may 1 o:cd fur secnndaI <br /> purposes in accordance with the Privacy Law,ti15.04 I (n) St ds (Cott <br /> _� 1*3,3LM � N �� n�J"- <br /> L Application Information Please Print All Infonnabnn - 1 _ <br /> Property Owner's Name fill tccl N <br /> L S' a,Jef_' k'- - -- - Letud :011 Gi725 o53aa <br /> Properly Owner's Mailing <br /> �Address Property Location <br /> S Govt Lot <br /> e 7 - L - - ! / / <br /> City, <br /> State I.SS(S / �V IJ/utul .SJ -l(i/A I �In Nan[t� uclfiun _ ( ,•, <br /> Y W <br /> enc) <br /> ,Into <br /> Il 1 v r,of 13u11dm' check all than apply) - �� <br /> 000drvisr '1-- <br /> ❑ 1 or 2 family Dwelling-Number of Bedrooms <br /> t-L <br /> V 1❑Public/(bmmcreial -Describe Us'c-____._ .. ❑ City of <br /> CSM Numb,,, ❑ Village of _. <br /> ❑Stale Owned Describe Use <br /> 9"Tdwn til'._. /4.G s0"j <br /> . _-- ..__ --- — _ <br /> III I ypc of I t.rmit: (Check only one box on line A C nmplete lint.13 If applicable) -,-_- -- - <br /> New System ❑Iteplacentcnl System �� 011ier Modilie than to I:xislin,System xxlaini <br /> �� InnnrcnVllolArrrg lankR plr nrcm Oily 6 Y (c <br /> - <br /> - U;I I rcvreus I'ennn Number and Dvle I++unl <br /> If. L� Permit Itancwal ❑ Permit RcN9ma [� ( h mfo til Plunthu l �)I[nun Iii sfm to N", <br /> _ IV In Pressu�r�<WIn-Ground <br /> System/Cumpnnuttllhwee: ((hccl<:JI that apply) <br /> -Ground ❑ I ressurved ht-Gi naal fir\r-1 kodc B] rMomul ' it il.til so ellIC.nil (1 Mnmtd<24 rn of saitolle sod <br /> ❑ IIoI0ing Tank ❑Other Dispersal cor poen nr(explai)) _ � )-Pr Ircvinrenl Davie. ex linin)_ <br /> l I <br /> V jjiDu crsal/I'rmtlmmrt Arca Information: - _ _. ___ -- <br /> Design Clow(bpd) Dcsrgn Sail Applr(Capacity rn(bl ) I l` 16r1 111 1) o psi al Acca I rnpuscd(eQ- Systl,rn 8lcvuuon <br /> rdsf Dr+r oil Area lta need is <br /> 1 Y �6v -_ <br /> al Manulhchucr <br /> VL'1':mh Into I Y n, `o <br /> ( Jlom (introns Units � .n V u 'C <br /> sin <br /> C3GI-qc� <br /> _ _ l 1 <br /> S tit or Io irk <br /> __ __— --- <br /> rhniug tharnbc _ --- - --- -- — 1 - <br /> - <br /> VII Responslbilky Statement- 1,the undersigned, r+,urie responsibility far inst.dlatmn of the IOW 1 S shown on the attached plans. <br /> Plumber's Nvme(Pring Plumbers Signature MI'/MFRS Nuntbcr ALIs11lG,1I h[ne Nu ober <br /> I'lumber's AddI (Street,city,State,Lip Colic) <br /> VIII.County/DS vtmenl Use Only -. <br /> /' — - Pcrmir Pec Date Issued Issout),Age nature <br /> lid Appiovcd l L] Disapproved <br /> L❑Owner live,R_a un for Denial <br /> IX.Conditions of ApprovallReasons for Disapproval <br /> ppIxdcB4cT Te b<- <br /> amelElvo�y ow �oT �{sr how bo�i� /adfdrewo(f$Eot?. <br /> 11 <br /> _. .. .-,a,r.. -- r ,.ii <br /> r i:.;.a-ra. 1 I.K 11n.. <br /> ___.. nvxehm_enmplei"for1-rar me,) i. r:in,i+;Innn r.ti.t ..l>a It <br /> tiRD-1 39H(R. <br /> ()1/()7)V olid do"()1/()9 <br />