Laserfiche WebLink
.ra:1.k- , Industry Services Division "� -7'r <br /> fy� 1400 E Washington Ave r_AA ~ <br /> :w'1 �4' P.O.Box 7162 �Permit Numbs( be filled in by Co.} <br /> €yi �_!s" H: Madison,WI 53707-7162 <br /> cJK�`l, - /4'sZ <br /> b r� CT -la7 <br /> State T Number <br /> Sanitary Permit Application �� <br /> In accordance with SPS 34321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application forms for stain-canned POW IS we submitted to • t Address(if different then mailing address) <br /> the Deparhmoed of Safety and Professional Services.Persorral information you provide may be used for secondary <br /> purposes in recordanee with the Privacy Law,s 15.04(Ilm} Stats le=J(7 e 71'' 8 <br /> L Application Information-Pk*ae Prant AB Information <br /> PropertyrOwner's Name Parcel# 07-030- Z---5T-4,23 3 <br /> \/,tl(_t_/E ga 1A 5�/t 03- 000--011 000 <br /> Property Owner's Marling Address Property Location *2624 <br /> 12.35 J, tiop cit.'. S u r?E zG� comb t ml- <br /> State <br /> city,Ssa <br /> � " Zip Coda Phone Number Si1V '/ti 5 y+� v., Section23 <br /> 1 <br /> +�( (circle arae <br /> >ynt{ 1OA), IL` l '77t 76- 34k �g77 T .3 N; R /(p Eor <br /> IL Type of Baildia (Beek all tint apply) j Lot 4 <br /> Subdivision Name <br /> )41 or 2 Family Dwelling-Number of Bedrooms_ <br /> Block 4 A)A <br /> ❑Public/Coamieminl-Describe Use ❑City of <br /> CSM Nun bcr 0 Village of <br /> ❑Stare Owed-Describe Use _ I /�'r <br /> -� Ai Town of ----W& �+ <br /> III.Type of Punic (Check only one Lox on Lae A. Complete line B S3pplieable) <br /> A. "Yew System 0 Replacement System Li <br /> Treat ment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> ;.Type of POINTS SystaniComponentiDevica (Check ell that aptly) <br /> Nora-P es slam In Grand 0 Pressurized hu-Ground ©At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.o�f stutable sail <br /> /"" <br /> 0 Holding Tank Other Dispersal ea mpomea(explain) F/ 3 .4 )` Pretreatment Device(explain) (n> ) ;M.f!T <br /> V.Dispernilffrciancot Area&formation:_ I l t $ S(.�- se_ I <br /> Design Flow(gid) Design Soil Application Rafe) Dispersal Area Require!(sf) Dispersal Area Proposed(if) System'Emden <br /> /5D 2.0 '75 77. 5 R5 <br /> in Total t1 of M.'as+faau err 2VI.Tank Lifeala s Gallons Units a C U S <br /> New Tants F log Tonka 1 oS Y . 11 St w 3 <br /> a.O in A in w a, <br /> DoriegOurabte G <br /> t . 5OU <br /> eaoa of the PO.Vfs shwa on the attached glans. <br /> Phu er's Name <br /> n Statement-1,tie°adeesrgaumed.is Siassum ,Nwn� Business Plume Number <br /> Plumber's Nrn+e(Print) Plumber's Si <br /> (tor'Y 3: T,�eKseAv - /,/ , 5 2-4133 715-S� --?'`h / <br /> Plumber's Address(Street.City, r n zip Code) / <br /> 930& iJifrACIK BRCVKP-B", wOSOS ka SEgR3 <br /> Vin.Coattty/Depuutmeat lin _ <br /> y.�� 0 ! Yertnit Fee i <br /> Dinner ling A t Signature/ <br /> 4Pptovsd 5 1// Q <br /> 0 Owner Given Reason Car Demi:lp 515 4)45 <br /> IX.Condit of ApprovallRe tsoses for Dis:mpri t/al <br /> MIAs trio+ •C. <br /> Ad <br /> �t,t.1e t aib4, `,ur be pct 41 12//2020. <br /> 1d eesSiett Campos eM I rite cuotE psi be 14st:ce Ar fiver 1451011044 <br /> Amman to eesr?bale eon.for the system mid siAa,@ to n»Coag erts no Pipet sot Ina tiLam 8 i• Ell n/)' [ <br /> SBD-6398(R.(18/14) <br /> JUL - 1 2020 <br /> c urnett County <br /> Land Services Department <br /> Cfr# 4iS;6 4174 00 <br />