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Apr, 29. 2009 9:50AM , ,,,,, . iii F#; No. 0381 P. 1 li [1., APR 2 4 2009 ( tj 1 commerce,wf.gQV Safety and 13tliidings ivision County — -__... ... - 7(11 iillYll hlvjt101i YT,T .Box 7162 '1 )�t•�e'C ati � �� i r,Vlfg�)t E3i?,?S;wiCS L 7-7162 Sanitary Peruut Number(to be Cdied hi by Co.) Department of Commerce -- - S StateTransaction•Ntunber anitary Permit Application _,5 jg o't 6 In accordance with s.Comm_8121(2),Wis.Adm,Code,submission adds form to the appropiintc governmental unit is required prior to obtaining a sanitary permit. Note:Application farms for state-owned PO1WTS are PmjcN Address(if different than mailing address) submitted to the Department of Commerce_ Personal mibrmation you provide may be used for secondary urposes in acrnrdance with the Privacy taw,s,ism(writ Stain rK� ApplicationInformation-PleasePrintAltlnfarmittion - - 267 � C� t1 Property Owner's Name Parcel 0 .•__ ._. . ... .--•- - h - A /(Ais I c4 ?s e 71A_ "4,..//- ) 4/1/- $e)e l-a Property Owner's Mailing Address Property I.ocatidm..- (14/i? A/ r, 1'. • Govt.Lot__ City,State Zip Lade Plante Number ,./ , \ 4J7��C- CV �3 6 d1 Loy.e�7 3^ l 7 /7 'r Ni R f t�(riff e) 11.Type of Baling(cheek ail that appl)) Lot U - - ❑1 or2 Family Dwelling-NumhcrofRcrire 3 Sidtdiviciarl'Namc - / Block ti ❑Public/Cnmmercial-Describe Use - -- ❑State Darted •Describe Use GSM Number - ❑village of _ -- -- Town u.0 PL 0-)S?9t.3 p+r1... • ILL.Type of Permit: (Cheek only One Ilex ern line A. Complete line B if applicable) A. Mew System f Replacement System 0 Treatment/Doh/inn Tank Replacement Only ❑Other Modification to Existing System(explain) R. (]Y-mlit Renewal ❑Pei tali.Revisiun Li C:hangc of Plumber 0 Permit Trarafer to New 1'i. Previous PetinitNtuntret and Date Issued Before Expiration -Owner TV.Ty of I'OWTS System/Component/Device: (Check all that apply) - ' pe fi r N m t-P r e s s n t i x c d in-t;mind iJ Presser-fed In-C,totmd ❑At-Grade ❑Mound>24 is of suitable soil L i Mound<24 in.of suitable soil - ❑Ilaidine T a n k U Other Dispersal Component(=plain) ❑Pretreatment Device(explain) __.•._ •_____,. . _ V.Dts rcrsalhi'reatrnent Area information: Dcsiget otv gpd) Design Soit Application'atc(gpdst) Dispersal Area Required(sI) Dispersal Area Fropdsscd(at) System}�cvation S�C) d lid- --- L f _CO n 9, i 9t2.4, f.3,12 23;4, V 1.Tank Info Capacity in Total got Manufacturer Gallons Gallons Units v v N 'Now Dana' Existing Touks _, 11 2 g a .n. A rn a in F,t3 a. Sends or Holding Truk /66e) /vl,b / e..eestk- Doting Ciwmbar VII.Responsihility.SLatetnent-1,the undersigned,assuma respo thllliy re installation of the PO11TS shown en the attached plans._ Plumber's Name(Print) Plum∎•r's Si- • MP/IvMFRSNumber Rosiness ftmhonc Number 5-3o'feiL \ ro.sSj r . — c20.1 76.e5q o )15,121s-7.. 7/ Plumber's Address(Street.City,State,Zip C: •) �1 —- ? .5:4,f ..x9G.,''I 1;1 C004-'i" Oahe L.U�t" 5-3.F.Ai ,� VIII,County/Depattment Use Only — _ Of j � �,� PerrnitFee Date Issued Iss', ,is :fgApprnvcct ❑nimppraved fl s S t) /° 41110-1'.4,b4411-‘11°/'' r Owner Given Ltcason fur Denial '� - r i' 1.X.Conditions of A 1 • • Approval/Reasons for Attach to complete plans tar thesystem cad submit to the County only on papernot Inn!kw a in x 11 inches in size DB--- q 361 I _ SBD-6395(IL 01/07)Valid flint 01/09 0ku— LiQ'1,cn".7 .