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• <br /> •�' aerie TO Y53.r•x 0 Csr,_ Keys, <br /> t. 1 t Z008 Safety—and. <br /> afety and Buildings Division County 'A►► <br /> 201 W:Washington Ave.,Y.O.Box 7162 J K�e <br /> • i scoins i n - . • • .Madi W1 S3707-7162 Sanitary rermit Numb be 1 by Co <br /> Sanitary Permit Application State Transaction Number �,L/Q/7n <br /> In accordance with s.Comm.*3.21(2),Wis.Adm.Cock,submission of this form to the appropriate governmental I! mild J / V I /I <br /> unit is required prior to obtaining a sand Application farms for <br /> submitted to the �Y permit. Note: attbe.pvvmLd POWYS cn are Project Address(if different then main address) <br /> Department of Comrmrerct, Personal irmfottraatieee you provide araey be used for secondary <br /> E sgs en in accordance with the privacy j_ s.13 Wi t xm) Stets o <br /> I _I. Applieatior Inforenntion-Pkone Pratt A4 information i 3t%� `/e r-- J <br /> Property Owner's P.rcet Si <br /> r rc fac S <br /> • <br /> Property Owner's Mailing Address Property Location <br /> t 1 ' S, '—*11 <br /> City.State � Zip Code Phone Numbs Govt.Let <br /> Vr� �L 15 S 7. �1t 'ti. /1�� SG, Scdian_ <br /> IL Type of Budding(cheek all that apply)'' Lot�t T `� N: R '(c ( W <br /> O't'or 2 Family Dwelling—Number of Dearman �4o <br /> �Subdivi4ion Name <br /> ❑Ytblic/Commerraal—»teeUse 81ock! l��. (X/I('0 <br /> 0 city or <br /> a Slate oanett—D«eaibe Use <br /> CSM Nambet 0 Village of''',�J <br /> _ IaTownof T er(`l <br /> �Type of Permit-. (Check only one box oa lire A. Cerrp�line B if applicable) C <br /> A. <br /> Tr New Sy'man 0 kaplaceatent System 0 Treatment/Holding Tank Replacesnas Only ❑Other Modification to Existing System(explain) <br /> a. ////❑Permit Renewal d Parma Reunion 0 Change of Plumber O Permit Tr nsur to New � r e�toaspamitN�mba.ad nay Limed <br /> Beim Expiration * <br /> Owner <br /> IV.Type of POWTS S o t/lkwioe: Check all ekst <br /> 0 Nora-Ressuriud in-Ground 0 Preaanari la-G►o►md ❑At-trade 'ifMmmd>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Preaoatawm Device(explain) • <br /> V•D >mirts great Ares Information: <br /> ? "W ) Doman SOU Applieatioe Rat a f) Dispersal Ara Requited(sl) Dispersal Anna Proposed Of) Sys em Elevation <br /> n.lt u>re <br /> I. d Sao 5�rd ,Y. 7 <br /> Capacity in Total CZ Manufecturer <br /> Gnus Gallons Units ° _.0 New Tasks nineties rya a g u $ a <br /> r..0 rnx in 4u a. <br /> Septic aaiWaiaaTrek a6©o SO t <br /> 'QZr fi <br /> )>osiaa tle.eaar I <br /> •VII.Responsibility St* I,mead ea,assume . knteNe ion ifs a POWTS Aeon as the attached ptae,. <br /> Plumber` Wane(Print) -- �" MPI RS Number Busmen Phone Number <br /> e - O2v,} '� `. <br /> Plumber r•Address(Street,City,State,Zip Code) <br /> : ∎ ?�5 <br /> 73('/ —bu —im•4■.. Ce c 4- .Jade., i F 5-3 S-02 7 <br /> VIII.Coro e • rtmeat Use On <br /> 0> Pertait Fee pate Issued T Issuing Agent <br /> 0 Owner cites,Reason Reason for Denial s�+ or "7.43s fy - <br /> IX.Cenditfors of ApprsraVRaasona for Disapproval �w l G3 IN Cit�FJV"f itVG THIS Opp <br /> �C� POW 7' /1.0w ENV RONMENTAL HEALTH D O'DANE COUNN <br /> LIABLE FOF:.gnJY DOES NOT HOLD ITSELF <br /> DEFECTS IN PLANS OR SpEcocA• <br /> 7IONS,PLAN OMISSIONS,EXAMINATION OVER. <br /> SIGHT.CONSTRUCTION OR ANY DAMAGE <br /> AWata a,eagtr a Am Ar ae ryliaew real mesa*le the C..ary eel/w"per . , ' 'r ' "', �,, t f ,TION AND RESERVES <br /> SHOULD CONDITIONS R SE MAKING SONS <br /> SBD-6398(R.01/07)Valid them 01/09 NECESSARY. ! <br /> ZOO Q) 919jjej�ad$ �T3daS 8t890S8809 YV3 I'I LO 8002/0T/OT <br />