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Divtsion <br />hxlu&y Services <br />1400 E Washington AIve <br />P,O. Box 7162 1 sanitary Parnit NuwmnbtT be Skied in by [:04 <br />W1 53707-7162 <br />R a� Permit Application �t­_-rrarmd im N urabar <br />Sanitary 4 <br />In accordame with SPS 383.21 (2), Wis. Adm. Code, submission 0I fiinn to the apploprlEke QDV �7j�LZ_t A ��m (if d— <br />me <br />is requind prior to obtaining a sanitary perinit Note-. Application ibrins for stwz-Owne'd POVnS iu:nub;r= P�l 11fi3ent than mait"S "W"') <br />the Department of Safety and Professional Services. pmongj itunrinaurin you provide omy be used for 50condnI CmA4 RD, 1, <br />mirposes in accordance witli the privacy tastw_ <br />Law. s- 15� <br />L plrine Paist A] , 1 1,011bramadam <br />.poftenew Pmel 4 <br />Property Owna's Name J5�3'17- <br />A), l or Property ownces mailin- A'Idress 02- q��'00 <br />'V 2 / WAP�4,SH A Aj, Fitz e Number GQVL bit ti." 31" <br />City, Staia See <br />(circle <br />2- <br />PAU C 'M'� N . R <br />—i Lot 0 <br />11, Tm ofDrya' dins (elmh $414 t4ul RPPIY) Subdivision me <br />or 2 Farnity, Dvvelling -Number ofBcdulmns 2_ <br />Q ate <br />— <br />Public lCommercial - Describe Use 0 city Of ____ I <br />Cs Number ❑ Vill,:-gc of <br />nSurte Otvad -Da9mbe USe <br />----------- <br />Ill. T�rpz Gfpermiu (Cb=% only One box aim Dim A. COI Ikem <br />4 44 *ul Property <br />C"' 1 S21 11, TM OB.'I's febwt rvi '2 F.ih'3�11i�-Numbw &B <br />to F�dsfing System (exqiwn) <br />A. Mews YSWM Repleeernem systern 'Treaunent/1101ding Repteecatent Only <br />-r' <br />—en - - T� <br />- 20V1 <br />prI Perrait Nmber and Date Ismed <br />List <br />R. 0 Permit Rerwwal Permit Revision 0ChangpofPIumb:r OP=it-1'MSf:rtuKew <br />r. :=' R—it zi icnot _.. of <br />Expirwor, set <br />Tyme"Of —POWTS !y8w9co anvDavkC.° (Clwek an that aRR!Y <br />2!RSO_ I---- <br />0 Non-PRoI 1111 0 Pres'&O=d Ift-Ground 0 At-Grde 0 Mound > 24 irL Of suitable SOR El MGkild < 24 in. Of OAab'v soP <br />XHcWmgTwk OMiurDL,,per,,oiCompaq A(exPim") Device <br />calw=j Arm livibm <br />Requi Elm"don <br />sea Design Flow (Vd) Dew Soil Appliczmariadoo; Rate(OPCIsf) D"Pcmal Am -red (sf) Dispersal A <br />fac <br />V1. Truck IS&FofCapeeity in TOW <br />Manuturer <br />GW 'law Cations Units I k <br />0 B 2 <br />ss J <br />w�Raldkrg T07k co <br />Dosing O=nber <br />N EL R=pwAbM1y Stavemseist- 1. t" am&Ta-*M 1"? for mateltaftm of tr2le PG%VTS shoTm M, the SUMI view. <br />Plumber's Naniz (Print) P1 hei's Si i i1h bczBusiness Phone Number <br />11OAV -71 VIII/ Y <br />Pluatber's Aftm (SueM City, State, Zip' -Ode) <br />q30b j��eK 89COK F-b, <br />VVIL Coen* rtamt fist Oziy, <br />Date Issued Issuing Agent Sign.I :'C�' <br />0 Disapproved Permit$_ <br />-1 0 owner riven Reason for Denial t 1,5— - / -__/ -1 _- <br />N <br />ME= <br />SBD-6398 CiL 08/14) <br />to tkz C=,Ay eatj an papa aw &23 ram a 14 <br />APR � j 20199 <br />Land Services <br />