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t o-&- t.v.N•�� �v.--1 J 1J� 1.7.)•10 1 L- 1-HA: N 1 <br /> `y hilll ten iiv1i;7 O1\'i)1o11 ('nLLnl}, - --- -- •----'--• <br /> 201 W vr'&shington Avo . 1'O. Box 7 l62 �a!� C-) - �',�� <br /> 4 I sct�lisin t44ndison, WI 537(17 ri62 ->;ii•AJdress <br /> Department of Commerce• <br /> Sanitary Permit Application Su tuwryrcnmI Number <br /> In&.enrd with Comm(}3.21,Wia.Adm.Code,personal Information you piovidc I ' C� <br /> may be used for seconu'ury purposes i'rivacy few.s 15.t14(1)(m) lawcA i1'11rrlcinn <br /> I. Appilcstlno.Information-Katie Prittt All lntomatlnn SvW' Mini IT. .n►r*_ - -"— <br /> Property Owner's Name _.._...._. <br /> ,p� � All Parcel Number <br /> �1i`' '""%i f ©IA-,c t _ 0—g <br /> Property wrier s Mai ing A ■rc„ - - — /fir <br /> pity,State 2 3' C Ls C .. L) p t ,t IVA e'd-{)';5•��� i" N,R /1 E <br /> ip ode 'one `umn er Lot Ntunhcr B no um et — <br /> CO _ Sut) Yvit�amc D urn r <br /> � 1/64,� 6 r Q. (/...lx V7 C <br /> IL Typo or , tdin�(C�tcek aft that wp ty.) - f* 3��` CS 46 <br /> �1 or 2 Family Dwelling -Number of Bedrooms Ott)' <br /> ❑ PubliclCommercial-DescribeUse -- these__ _ <br /> QStatc Owricd - IClitnwnshtn T •�t' <br /> its. Pe a Pbrmltt (t'1tock only olio box on line A. Numbering Is for i ternal`tr `/ � G,r ��S r <br /> WAN <br /> _ it �u.) (Complete Ilne �3,if aPp(ic le,) <br /> 2 Etc 27114 laccmonl of 60 ditlon to <br /> ❑ placement System t. Dni g !Awn r, - ._ • ounty woe <br /> Ex' rin S /'� _�� <br /> Last Lit if Sanitary permit Previously Issued ?Permit Numoer t• _ Dale Issued <br /> IV. ype of POWT System: (Check silt tint npply. Number ng for In ornefaao.) `--1 <br /> 44❑t-on-Pressurized In-Ground al QMound 47 [y`anct Filter 56'©Constructe WcIIand <br /> 22 QPmsnurizeQln C;round <br /> 41 Q I folding Tank 4fi 6i5 iieTass z ` 51 CI drip Line <br /> tAt C»dde Cr), \ <br /> 4n OAcrobie Treaunent Unit 4 a Fliyfuotaiins :30[]Other <br /> - <br /> V.Dlsparsalirreatment Area Information: r <br /> Outgo flow(gpdr-T Dispersal Area (1ispersaiArru %oilApplicatiun '-`-. -r:,:$erco iunAate , ystem elevation FlnAI(}rude Required Proposed Rate.(Gal .IDayslSq.Ft.) 44Innncit) Fleatlon C i Q1'7 10 <br /> i.b <br /> VI.Tank Info Capacity in`-- ! Total urn er - e f <br /> gnu ncturcr Prefab Sitz Stool Fihar Plastic <br /> Gallon: Gai'wns ot'1 rotki Concrete Constructed Glass <br /> Naw Existing <br /> Tank* T&nki <br /> 1 Sapkic or 1-inlei4t. u, <br /> 00 =►R.+ a(funnbr r � ('1 <br /> VII.Responsibility tat�rnn - I I --_ i <br /> ty t I.Ilse underei me. &same reepoasiblltty fur lillarlon of the POWTS:frown on the attacked pions. <br /> ler s'ime •r nt rum ndt r fin. , `uni er Business Phone Number <br /> 'um•er s A•dress t, fly .tqc•Zip ro, — .- - <br /> °_6,1...7- <br /> I , own ;w.artmen I ern l [ _ _ V L/4�� 5,1 <br /> ❑Di`sappruv -� - - /� <br /> Al Approved {❑Owner Given Init'• Adverse <br /> Sanitary I'ermn Fee(include i;roundweter ate Issue Issui Agent SI nest �p`fr7t'" <br /> iurcnar a roc / <br /> Determination Y ) u 70 - ,Wig_ 2 J �._ <br /> L'•Coaditlorts of ApproleAl/Reaaoos for DEtlapproval / <br /> Arne met 00' Tana(la in Caarr(Y ur the ryateut un,a&per nut Jae butt 0. /1 txchw.leJilt <br /> ■ <br /> SBD-6398 (R. 05/01) <br />