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608-831-8107 MEINHOLZ EXCAVATING 049 P03/03 SEP 29 '08 12:17 <br /> .. SEP 2 4 200 b <br /> . Buildings Division County <br /> . ash MD .W „ ,,, Ave..P.O.Box 7162 (,Yt <br /> i sCO $Krieroo • --•n,WI 53707-7162 Sanitary perm 517 filled in by Co.) <br /> State T ✓n� it Nu ,actioa Numbs <br /> Sanitary Permit Application <br /> In accordant with s.Comm.03.21(2),Wit.Adm.Code.submission of this form to the appropriate governmental Address(if different than mailing address) <br /> to obtaining•sanitary permit Note: Application forms for ale-owned.POWTS are Project <br /> tartan is required prior Personal information you provide� be used for secondary submitted w the Deportment of Commerce.�15.04 t,s Stars. <br /> 1.. in accordeme with the • <br /> I. A, •nation Information-Please Print All Information p N <br /> Property Owner's None ,pt� Csr1'f TnC. d7oe3-3?2-ZoF� O <br /> Ale KQ v'Wt2A/ Pcopetty Location <br /> Property Owner's Mailing Address <br /> 3467 F31uC fj(gGar RA. Zip Code Plume Number NW %. NW 5G.section 32 <br /> prude era) <br /> City, Cry& try t 53g,3 T 7 N; R (circle <br /> cheek all itbat apply) Lot N <br /> II.Type of Building(cheek ('o <br /> Subdiviaioa Name <br /> el or 2 Family Dwelling-Plumber of Bedrooms Blodul itg [,Lace• V. I • <br /> 0 PublidC mmerciat-D e s c r i b e U s e_____:,.---- City of <br /> CSM Number 0 Village of <br /> 0 State Owned-Describe Use L'Towm of Nli 2A tt icra <br /> M.Type o f Permit. (Cheek only sae box on line A. __ • ate Ilse B if applicable) • <br /> �jmv System ❑RCpiaatneM <br /> i'Qy \ r.., .,, s; 0 Other Modification tofxisting System(explain) <br /> •' •Transfer b New List��Persil Number and Date issued <br /> 0 permit Renewal 0 Permit Revision 0 Change of Plumber Owrna ,{� : 4- -Ow <br /> Bt(ore Faxpinriorx <br /> IV.T s, of POW TS S tera/Com• t/Device: Check all that a. .+ <br /> >n-Ground 0 At-Grade 0 Moo 24 in.Dislikable soil 0 Mound<24 in.of suitable soil <br /> 0 Non-Presser acid In Gtorad ❑Pressurized Pretreatment Device(expiaia) <br /> ❑lidding Tank ❑Other Dispersal Component(aP�+) <br /> V.Des,creel/Treatment Area Information: v Ate Proposed(� System Elevation <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) D •- - Area Required(si) Digers <br /> (4,00 7 1-0 •- ` •�' (000 teCO Sat AO rte.,• <br /> Manufacturer Capacity in N of ffi e u <br /> VI.Tank Info Gallons Units i # 3 ;I <br /> w <br /> New Tokio Existing Tanks 1 V 1 I 1 u.3 a. <br /> Ii i taco I NlGble X �-� <br /> thr.xba � — 900 ( is X <br /> R6+/NlPRS Number Business Phone Number <br /> VII.Responsibility Statement-T.the radersi acid,spsaax responsibility for atstaWtaaa of the TOVM'IS shown on the aHaebed • <br /> Plumber':Name(Print) Plumber's Signature <br /> ..4..A VKAse W. MG14•o1L � M — Lu_ ')•1".- 2.2e1L5 A3f•81o3 <br /> Plumber's Address(Street,City.State,Zip Code) <br /> (d5I3 GTN• 14 1,IGlunaku.VSI 535'37 / <br /> VIII Cora ri <br /> . amest Use Dux Permit Fee Date Issued eiliWZ I Approved 0 Disapproved s C2`7 i" / -2('6 0 Owner Given Reason for Denial .,. . .C./ , ., ••' , 5,1' o+•� <br /> IX.Conditions of Approval/Reasons for Disapproval ENVIRON ' •j,HEALTH DOES NOT HOLD ITSEL= <br /> • LAKE •• .1 DEFECTS IN PLANS OR SPECIFICA- <br /> TIONS,PLAN OMISSIONS,EXAMINATION OVER- <br /> SIGHT,CONSTRUCTION OR ANY DAMAGE THAT MAY <br /> , -1 :a : it, _, a : •, -s <br /> muck a e aeprae pion for the Mum Pad sub.ut t.the Coa,Ny"al aw paper <br /> aa !aI Pfri *CHAN ADO ONS <br /> �8-' a to Zero 0�- - S E Sl �NG <br /> NECESSARY. . <br /> S0D-6398(R.01/07)Valid thru 01/09 <br /> • <br />