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• Apr. 16. 2009 11 ; 01AM. ; , 1 1 • No. 0298 P. 1 <br /> ;'1 . ,,, it `�,i • Comm T <br /> tiii.. totnrrtsioe.WI ! •V . Safety' ildings Minion County 3 Z.M.W,NY:•, Ave.,P.O.Box 7162 ea n t <br /> ■ e... ,i ' E.... ., .F • 'i LMadison, 53707 7162 Sstotary Permit Mader(m be 531ed in by Co.) • <br /> Dapartmerd of 5/8 a 4-7. . Sanitary rermit Application - e r - <br /> ....In a000idanca with a. Comm. a3.21(2), Wis. Adm. Cade, submiseion of this tom re the appropriate L 5 4_ 5+e( <br /> governmental unit is required prior to obtaining a sanitary permit. Not Application forms for slate-owned Project Address Of different thin mailing address) • <br /> 'POW'IS aro submitted to the Department of Commerce. Personal information you provide may he used for <br /> ..._fro is accordance whb the_ Law.s•I/...M. ).Smts. w <br /> I. Application Inforrmafiein-2? Print AU Information - <br /> Property Owner's Name - <br /> Property Ownes'a Ma fling •. --7 , pkepesty Location <br /> al c;e.) +r- 6 .. . Oon.Let <br /> City,Star Zip Code , • Phone Number /Vv.) it, /Vt.,/ii,seetion 2.2. - <br /> ., • • •w {.. to 3) Sic?et'- Lush 5- . T to N; ( oieone) <br /> R��or.W-. <br /> II.Type of Building(check at1 that apply) Lot/I . <br /> t Subdivision Name <br /> i8-1 or 2 Pandiy Dwelling-Nmabsr of Bedrooms / _ <br /> . .. B1ock N <br /> 0 Public/Commercial-Dea7ibe Use _ . El City of <br /> "ChM Number - 0 VMS°of t <br /> ❑seats Owned-Describe Use g Town of _e1 u P n u rani . <br /> ILL T y p e of P e r m i t: (C h e e k o p t i o n.box on flats A. Complete lino B f#applicable) - --• - — <br /> A' Q New SyttSrn 0 Replacement Systmr 0 Treatment/Flo- Tank Replacement Only 0 OW Moditication to Uxisting System(es i8in) <br /> B. ❑Pest Renewal 0 Parch Revision ❑(barge of 0 Permit master to New Litt Previous P'esmit Number and Date issued . <br /> Before Expiration Pena Darer ------- <br /> _---- .• <br /> t/Ai IC (Check all tons twit �--- <br /> Type of Powrs sir Camyoaet3 ' - <br /> ❑ Non-Pressurized in4iramd 0 Pressurized in-GrUund 0 At-grade. 0 Mound. ..24 in.of suitable soli $mod<74 b.or eoitablo sou <br /> 01loldbrg Tank 0 Other Dispersal Campcment(expW*_ 0 Pretreatment ' '' - . <br /> V. I Area Information: <br /> ■_: _,..• . (gpd) Design Soil Application Ratc(gpdst) Dispersal Area Requited Of) Dispersal Area Proposed(s) System Elevation <br /> • o.4a 75-0 '75-0- • . r1 7 <br /> �'anitr , Capacity in . .: if or Mmes <br /> Gaumna Units g 1 -1-1 .1 <br /> •NewTaain Dining Tadw 1 H <br /> SeyEtcae'lttItIngtalk O P e 6r rites <br /> posies der /f700 Mffi 1 r e r- M INNS - <br /> VU. ' ::,.,. .„ . .s statement h site,,,, —. ., mamas -.. ,.,,; <br /> for hr fathom of she POSITS shelve eta the ettaebed plane. <br /> Plumber's Name(Prier t) 's MP/MpRS Numbs'.• 1 Phone Number <br /> p - ,2 AC.'19 & - ( ss)aaS .r 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ��� <br /> lit. CIuo►) R,/qq e Art f`i nr n a __ c i- r — — <br /> t t.County/Aeparlment'oae only ---�— - -- - <br /> . ._.- bate <br /> ved a Disappra Q Q /. - <br /> ' 1 0 Owner Given Reason for Dental yr'� "� + - .. ?4,(4,--i -- <br /> IX.Conditions of Approval/Kamm fort Disapproval r f <br /> -. 5E p2,471: /t/i/ 'C <br /> ” Anita caulpiste the i7amaaa submit to the Vends/anyenpolies no idsthisatexlimists insite <br /> SBD-6398(R.01/07)Valid tbtu 01/09 <br />