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$at6ty and Buildings Division County <br /> 201 W.Washington Ave,CO.Box 7162 Ill..,,'P <br /> iseonsin Mxdism W1 53707-7162 Senian,Perot Number(in be filled in by Cut <br /> (609)266-31512ro <br /> De artment of Commerce <br /> Sanitary Permit Application stare Plan I.D.Number (x <br /> In accord with Comm A3 21,Wis.Adm.CwIa,personal Information you provide <br /> muybeusedforsmondaryputposes Pri cy Ua sl5.W(I)(m) Project Address of,iffereat thenmaihngaddm'0 <br /> I. Application Information-Please Print All lnformati « logo <br /> nn _ <br /> 313 LOan Creek r✓- <br /> PrnpenYOwner'sNamc ,-,71I-Jul is Black% <br /> D,,anISebe/ T✓ast- CIX- aF//-OI - IfO <br /> Pm,ny Owner's Mailing Address Property Location Gov,t• tOT1 <br /> /V <br /> Ciry,Smm zipCde planar,NumMr, i ( N� <br /> �.-���G T NC— �irc <br /> /. pal/br LVt— T �/�N', ' LZ <br /> E <br /> 1,�1/.Type o[Bollding(chrek all that apply) <br /> L91 or 2 Family Dwelling-Number ofBedmemr 3 _ Subdivision Name CSMNumber <br /> ❑Public/Commercial-Ducribe Use _ T <br /> [3 State Ownd-Describe Use __—. ❑Gilt_❑Village Township or JiC <br /> III.Typeof Permit, (Check only one box on line A. Complete line B ifapplicable) <br /> System ❑Replacement Sysmm ❑T..trmoVHolding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal <br /> i: !I Revision ❑Change of ❑Pemit Tranafarto New Hat Previous Permit Number and Date Issued <br /> BeforcExpimlion Plumb« Owner <br /> IV.T sof POWTSS sfem: Chuck all that a I <br /> ,yNon-Pressurlwd In-Ground ❑Mound>24 in.i f suimblc sell ❑ Mou d<24 in.of suimblc soil ❑At-Crrade ❑Single Pass Saml Films ❑ <br /> Cunstmeted Weiland ❑Pressudzedla-Ground ❑Mulling Tank ❑Pet Filmr ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> ReametiatingS ntbede Media Filler ❑Leaching Chamber ❑Dri Linc ❑(iruvel-less Pipe U Cidam(explain) <br /> V.Dis ersaVrocatment Area Information: <br /> Design Flow(gptl) Design Sail Appliwlion Ratggpdsl) Dispcnal Arw Required(50 Di 11 Area Pm posed(sA System Elevation <br /> yso s Pao 9oa 93.70 <br /> VI.Tank loin Capacity in Total Number Manufacturer Prefab Site Steel Filar Plastic <br /> Gallons Gallons olUnim Concrete Comnucmtl Glass <br /> o, Eaton. <br /> Tenor Tvi4s <br /> GPlium lWldintl TaM rept /OOO <br /> Aerobic Trtsomos Oal <br /> Dr,rhamher 600 Edo <br /> VII.Responsibility Statement- <br /> I,IM1a unJenigneJ,assume responsibility for Imtallatwn or IM1e POWTS shown on tM1e nllnabed pinna <br /> Plumber's Name(Print) Plumbei s�Signaz/ujra ,y MP�IrMPRS Number Business PhoneNumber <br /> /z,Ck110?k.>IJ /d ✓AWP /r Clyl.r�s`/ 7.s- 8/i6 -4y" <br /> Plumbai s Address(Sur«4 Ciry,State,Zip Code) <br /> 7760 :K. ; 3's wehxylr� L.i� S'F853 <br /> V LCoun[ /De artment Use Onl <br /> Approved ❑ Disapproved SanitaryPermi[Fee(incl tles Groundwater Date Issued Iss ng en[Signat oSaunpa) <br /> Surcharge Fa) /( �COtyf <br /> ❑OwnttGivereReusonforDeniul Yf 1 .Lr'I W <br /> IX.Conditions of ApprovaVReasons fa r Disapproval F✓fUR6 SobpkW gray PENOmg- <br /> AmeM1 cwnpkh plata Irn the County only)for Meryarem on ppv nM Imr Mm 812 i II Imhn In ria <br /> SBD-6398 (R. 01/03) <br />