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I- <br /> H- Safely and Bu(Idir Division Cam. Dane �11, <br /> i' 201 W.W Ave;P O.Box 7182 p l� <br /> i $� <br /> Madison,4V1 63707-7162 Sanitary ioober tb be Meth in by Ca) <br /> 1 <br /> 13 -Zi 15-- aoo37 <br /> Sanitary Permit Application StateTronsacttonNmoberr <br /> to accordance with SFS 38311(2),Wis.Mm.Cade,submission*aids tam to thenppmpdete governmental unit <br /> is requited i prior to obtaining o sinkers permit.Mar Application thrum kr s owned rowrs ere submitted to . <br /> the Department of Safety sod Pmfesaiotmi Sacks Pe:raood.in!o/motion you provide may be used for Project Addresstif Waltman than mailing ndrLcssi <br /> ,r, -in with the Law a IS I.. in ' <br /> P+opmroarnel Infarwdo6—Plas eP�rintABLai Eldon Way Name V WV <br /> Frank&Wendy Warner <br /> x0512-054-7079-0 4°T'24 <br /> Property Owner's Meiling Addrsm FEB-17 206 6# �.tt �� <br /> Property Location <br /> 93 N.6th Street <br /> CO, rlVirpJ'►ea pp Govt.Lot <br /> Evansville,WI ....•.„,,c,. SE SE .section 5 <br /> U.Type afaultding(check au that •`' 9 Lot r! 5 N; R 12(circle <br /> $I 1 or2 Family Dwelling-Number.. : 3 29&30 Subdtvlslon Noma <br /> Block 9 Blue Meadow Estates <br /> 0 Public/Commercial-Describe Use <br /> 0 City of • <br /> 0 Slate Owned-Describe use CSM Number 0 Village of <br /> 0 Tam or Albion <br /> JI1 Type or Permit: (Cbgrlc al y one box our'tpie A, Couplet aline B If applicable) <br /> A' 13 New System 0 Rcplecemna System 0 TmatmeodliniellogT1mi** wmem Only 0 Other hioditiatIon to <br /> System'(c>cp)rta) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Omar ofPltsuer 0 Pamir Transfer to New List Pnevtoos Penn°Number."Dane tssnsd <br /> Before Expiation owner <br /> IV.Type:ofPOWI SystemIComponeniiflrice;((leek all that apptq.) <br /> ®Non-Pressurised In-Ground 0 Pressurized In-Ground 0 Al Grade 0 Mamd>24 in.of=kettle soil 0 Mound<24 in.ofsuhabie soiiI <br /> 0 FiokfmgTank 0.afxr niapetset Cow(esp i) a Pretreatment Device(explain) <br /> V.Diapersal/Treatment Area Informed= <br /> Dew Flow(and) (Design Soil Appttwtiem RnIe(gpdsl) Disposal Mm Rerpdred(sl) Dispersal Area Proposed(so System Elevation <br /> 450 I` 0.4 1125 1128 90.0'&90.4' <br /> VI.Tart Info Ch in Gallons i1 t+tmmfacturer e <br /> Nov Tasks ° <br /> Tanks , U � <br /> 3gatco a115g Teak y in E iJ a <br /> 1000 -�- 1000 1 Crest x <br /> Dud%Clamber 600 — 600 1 Crest x <br /> VII.Responsibility Statement-I,the undersigned,:miwaa responsibility No InstallattmrOdle POii't3shown ea the atiotlted plans. <br /> PlumbeesNsme(Print) Pimtber's Signature �iMPRS Number - Business Phone Number <br /> Raherf E L'-t/-sen bete/7/14- Se/e4d -i i a-Z- i, (d# )573-4Z-f <br /> Phanbej'a Address(Sired,CIIy.Sate.Zip Code) <br /> Sots-F S u: n iEd 1d G �/.l% 53. 75" <br /> VIII.Coantr/Depertmeat Use Only <br /> �Disapproved <br /> Permit Fee Dam Issued Issnittg`p z iyDetapy <br /> 0 Omterflivm Reason far Denial 3 y3 r <br /> 2-(3-2a, //J; //// c /41144.---IX.Conditions of ApprovalReasons for Disapproval <br /> friqtY4AVA Al AU/0149K ert 6i itdte' 6/4..C. <br /> Attack toewrplets*its for dimwits sad aka*to teeCounty capper art less Ikon stax II ieekntsats <br /> 6 ff (3 <br /> SBD-6398(1.11/11) <br />