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Safety and Buildings Division Counry ./�ya � <br /> 201 W.Washington Ave.,P.O.Box 7162 Yar r L <br /> iseonsin Madison,WI 53707-7162 StanyP<tmn Nu bar([o be filled In by Col <br /> Department Of Commerce (608)266-3151 C <br /> Sanitary Permit Application — State IanID Number <br /> In accord with Comm 83 21,Wa Adm.Curb,personal information youprovide <br /> may be used frsecnndary puryoses Pnveey Law,a15,04(p(m) Projeet Addasa(I[dl(ferentthan mailing nddress) ( 1� <br /> 1. Application lnfornmtioa—Please Print All Information Ilvv("�1 <br /> Pro 0 0'g Name pp4� Parcelk Wtx Blocks WI <br /> IIDD "_ I� ___- D _q 375- al �Fao <br /> �peny r 1 Mailing A�ss � ,perty Lodati'0� <br /> City,Stan (,IJI Vµ Zip Code - PLone Member "=/,/V /., Seclmn <br /> e(oS�r `l�3 g3K7 <br /> 11.Type of Building(check all that apply) <br /> KI or 2 Family Dwelling-Numbs nfaalromm _ lindic Name_ [� CSy Nlbar <br /> L2 Pobfic/Q.mmermal-D<scr l,o Use � 6 f-¢ rftT.Jl <br /> ❑stem ownai Describe Use ❑Cny_❑Vihaga XTonmehip.0d _ iu <br /> ct <br /> ❑1.Type of Permit: (Check only one box on It.,A. C ..plate line B if applicable) <br /> A. ❑ New System �fteplammem System ❑Trcatmem'llolding Tank Replac<n¢m Only ❑ONer Modification m Lxistin 5 ,sill <br /> g Ys <br /> B. <br /> 1: Permit Renewal L Permit Revision ❑Change of ❑Permit Transferor New iList Previous Permit Number and Date Issued _ 1 <br /> Bet—E aims I Plumber Owner <br /> IV.T e of POW <br /> TS System: (Check all that apply) <br /> Nor-Pressnrimd ln-Ground 0Mound>34 in.ofsuitaM1lesmil ❑ Mwntl 134 in.otauiuble axil ❑ At-Crede ❑Single Pass Sand Filter" ❑ <br /> JC-1ImII,d Welland ❑ P e sunced in-Goicul ❑ H Ro,Took ❑Pent killer ❑ Aerobia Ticarri Unit ❑Raomulat ng Send Filter ❑ <br /> J�.ovulaura,Synthetic Media Filter ❑LeechimikChoombser ❑Drip Line ❑Gravel-leas Pipe ❑Other(explain) <br /> �saUl'reatm.at A ea Information <br /> j <br /> Denim FI (,pill Design Soil Application Rate,maU D spersPl Arce Required(s1J Dispe sal Nea�d(sB System Elevation r <br /> l <br /> 30o Y <br /> ST.Tank Info Capacity m To � Number Manufacturer Prefab Sire St.] . Ihber Plast" "i <br /> Gollem, Gallon orum. Cunuete Ceramic'd Glass <br /> New picture <br /> Tom Tena <br /> UTt— <br /> SePnc NOIdinB Tark ✓' a-k Y <br /> Anub,cim,ment UNC /� �]r/ <br /> Davina CbamErr <br /> I FTI.Responsibility Statement-I,thea dere) ned.umme responsibility for installation of the POWTS shown on the attached plan. <br /> Plumber' Name( ' PI mbcieSignatue MPIPRS Number Amomass Phone�Number <br /> e(S o-er i 22522 7iS moo(, �b4� <br /> Plumber's Address(Snee[,Ci,y,slate,Zi Code) " <br /> `­7sxfs c� - Rd 1) w4s4f- F <br /> ,VJIL Coun Ne airmen,Use Onl <br /> IGalpproved ❑ Disapproved Sanitary Permit Fee(ineludes Gro dssatu Due Issued loan g ,Ignatwc amps) <br /> Surcharge Fee) - <br /> icDwnaflvenReawnforDental 1 $ y�y�•6/f`///��- <br /> IX.Conditions of ApprovaMeasons for Disapproval <br /> L <br /> A l.eh¢omple,o Pbm 4o rAe Coanty on')co'b" un vev.T nm ten m.n eta x worst in ntt <br /> SBD-6398 (R. 01/03) <br />