|
___• ON COMPUTER/SCANNED
<br /> commcrcc.wi_gov Safely u.tsl liuileinp.4)ici.itm— Cuunly ^ --" -
<br /> 21I1 W.11';tshiultun Ave_ I'.(1. Ito 710 !�{,J n."../
<br /> ISconsu, 1 Madison,R`1 537(}1 711+2 Sanitary Pcr tNumber(toI 'tilledinhy('o,)
<br /> Dopartmani of Commerce 4%' /„ i 9 53-a-lga-
<br /> S�InItary Permit Application Stale'l'ransaclionNurnher "'
<br /> In accordance with s.Comm.83,21(2).Wis.Adm.Code,subrnis.iunu!this linnt hi the appre>F,rlaic enstrnmeulal //`1' 3 3 33 - V
<br /> unit is required prior to obtaining a sanitary permit. Nutt: ,lpplitariue fuum> for rule-ur,nccl PtIll'IS arc PuRice('Ulf ens(if different than mailing addret.) (1
<br /> submitted to the Department of Commerce. Personal iru)i miatior you pren'ide /11.1V lit: ltstd Ito sXontar• �L
<br /> purposes in accordance ssilh the Privacy Lass.s.15.04(1)(m).Slats.
<br /> I. Application Information-Pk-ase Print All 1144)m:slim,
<br /> wmr's Nantc
<br /> Property
<br /> � !'erect� 03q'151(rot 3 a a
<br /> i ,i< e_ yd._,,,,) ___4.-4-..3Dsa) 07 -o34L2-37-I$•�G_rl-OZ-a .-oivu�_
<br /> Properly Oncr-a Alailing Address y Property l.ttcatiun
<br /> Gg/ t5'/Ja a K Ery, (ir„t.Lot
<br /> rill .Stale %zi /ipp code
<br /> y Phone NNuum�b]er ���� %'. �(� Sect ion _I
<br /> Cr r'4- J`t`` ," -W1 ..J-r . . S)57. �l -- l/ �, Icircle:one)
<br /> II.'I')pe of Building Mita all that apply) I.ot:r I. �. Nr: I2 /8 1f n
<br /> gIor gamily Dm ling-Nutnher of Piedmonts _ j Subdivision Narnc
<br /> '2
<br /> - IMO,.u
<br /> ❑PuhliclConorrereial-D)emc,u1,Use �'
<br /> --. ..' -- ❑city cut' r----.,..
<br /> ❑State(hs reel-- Describe Use �" ('S\l Number CI 1'illagu ul....
<br /> -- --, -- _. _.---- ,41„„n gr7/ ,4p, -..—.. ..L/7 .^. L
<br /> Ill.Type of Permit: (Chuck only one box on line A. 1'eltupietc line II if applicable)
<br /> 1' Kl lest/ stern
<br /> - (/� }'• J ❑ Replacement System ❑ '1�rc:qutcut:l lalJinl;'Irau4,Itcpl:rccmrnt only ' ❑ (Mier\htdifi.:rlion tut cisUng Syrian(cspl.,iul
<br /> it)
<br /> ` *��' List Previous Permit Number and Dale Issues)
<br /> Il. ?erinrl Renewal ❑ Permit Revision ❑ t'haul,ul'I'lurnbcr Q 1i.•rmit'Irauacr 10 N4..!%1
<br /> Rcfarc Expiration I rarer
<br /> IV. T-VI..of PO\I"I'S Sv stern/Com ponrrrt/1)es ice: /(-heck all Ow a1lrl9
<br /> ❑ Nun-Pressurized In-(!round El Pressurized In-Ground U_ I. ;rad: ❑\round_24 in.01 suilablc scull Klemm,•-:24 in.nl'snitshleseeiI
<br /> ❑ hulling Tank 0 Other Dispersal Component(explain) ___ _ -_ _- ❑Pretrcairnent Des ice(espkaiu) _ _ —- -
<br /> V. DispersaWl'rcamient Area Information; -
<br /> (go ) Design ! 14 ftl ) ----
<br /> Design Flow d llcat a Soil Application Mite ,dsl 1)i.pcos:,l ca!(oyuiru(Is1) Oisprr..rl,Ilea Pi (sl� System I?let:rtiuna
<br /> 3 h 0 �z 3 e� `J •7
<br /> 111
<br /> ''I.Tank Info ('apaeilt in ) fetal IS ill \lamb:securer -
<br /> u
<br /> Gallons c:allow, Ihill. a o g v
<br /> New':u,ki ' lixtslwg-I ant.. p G V u u r- . ;
<br /> u _ v .a n ar
<br /> L :n n tri C C_
<br /> J -----'"'--
<br /> Scrim or tiol rngTans, 7J "�� 75-0
<br /> (kxrry;t'tramler Q --- —
<br /> VII. Responsibility Statement- (,theundetsignrtt, essurnr rt-purniiilIt} for installali,m alto.t'Olk-I S strussel on the allachtd plans.
<br /> -
<br /> Plumber's Name(Pr' t) Plumber's Signature NII.511'RS Number 1!uaincss Throne NU/11110
<br /> I'lninhcr's Address(Street.Cit Slate.Zip Code)
<br /> gax s/y ...5, r, e. - w S—S'$ 7.2
<br /> VIII.IICount}'/Ueprrrintcnt Use Only -
<br /> }8.lpprovcd ❑1)Isapftrgt'gd rn,il I'cc Date Issue,) h.uine - -------
<br /> Pc
<br /> S M [�
<br /> 0 Owner Given Reason heir Denial 3(../{/° 3'/i 07 �e , i i r
<br /> IN.Conditions of Approval/Reasons for Disapproval 3/ Al5 Dai " '
<br /> /
<br /> '''e ii: 45 3a ict ,
<br /> Pef-60-.
<br /> )cp---_,.., c3-31._. g
<br /> Attar.to comp tr plans fur Mr sl slat,alit!•elwnif(011w C'uuuty only.n,I.,prr not Irv/than 9 I• a I1 fewer.in,ire
<br /> Slil)..39l(R.01/07)V;,r11d thra 01,0e9
<br />
|