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Wov riq 3$ ill C L U U l ckAt if s-s75 _ <br /> • <br /> _ ' ��H . U L 1 4 Zti: W-`I�;or' Ave.,P.O.Box 7162 A 2 <br /> ■ /�O I n . WI 53777-7162 Shy Permit)b lkr(to be Sled a by Co.) <br /> Bapastiasant a# . . <br /> vu hLSatui 'l ,, _ State Traossctiosiflambe: - <br /> In accordance wick s. Comm. 83.211). Ws. Adm. C ode, submission of this form to the appropriate .DVC--- ieW...(f.#' -11-c36(q <br /> governmemad mit is respired prior to abtai t a sanitary permit. Noss Application fora for Sate-owned Project Address(if diluent than min g addicts) - <br /> POWI'S are submitted to the Depmtmal of Commems Personal information you provide may be used for <br /> secondary twapusea is amosdnace with the Prissy Lew.s:15.04(1)(*),Sores. fl <br /> L Appifcatioa Liormail sa—Deere Priest AN Infarwtinn Ke m I e id <br /> Pmpay Owner's Name Ptnaei# <br /> C�e,r4)-0 t,) elle^ Os (O —oi3- 90c6 .-5-` <br /> Property Owner's Ida Nag Address Property Location <br /> 1 .-1-'39 Ke i i ' R,6 - Govt.Lot <br /> city,State Tap Code Phone Number. . i„� i4. S;.v il.Section . l <br /> r>11-. 14ar e b , w 3-3.5-7g (chyme one) <br /> II.Type of al thof apply) Lot# T�_N: R C a <br /> Sobalsion <br /> ®1 or 2 Family Dwelling-Number of Bedrooms 7-- tame <br /> Block# <br /> 0 PublirlCommeacid-Describe Use 0 City of. <br /> • <br /> Cad Number 0 Village of <br /> 0 Stage Owned-Dennis Use <br /> rd Town of Perry <br /> ILL Type of P+er*aiL (Check only one box on line A. Complete me B if applicable) <br /> A- 13 New System 0 Replacement System 0 TiatmendHddias Tads Replacement Only 0 Omer Modification n Brosdng System(eaPisin) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of 0 Permit 1tawar to New List Previous Permit Number and Dare Issued <br /> Before Explodes Plumber Owner <br /> IV.Type of POWIs (( k al that apply) <br /> 0 Non.Pseuwrked ia{kouod 0 Pressurized Ia-Ground 0 At Grade ®Mound 2 24 is of suitable sad 0 Mond<24 in.of suitable sou <br /> 0 Holding Tank 0 Omer Dispersal Component(explain) 0 Prrroteamest Device(rapid* <br /> V. Area Idataentb n <br /> Design How(apd) Delp Soil APPS sal Ama wed(el Dispersal Arm Proposed(sO 1 System Elevation <br /> 1.1 50 v. (a 1-1 So 4C0 ie.1i.©0 <br /> VL Tank Info Capacity in Tom #of _wdaanrer a A <br /> Gallons Gallons Units <br /> New Tads Edging Tads $ 0 <br /> Sepde of`Ha1daYTaak 1000 i 3.0o i 3 oo _ i Da1n•,a,rc C , X <br /> . Dodos amber 7 c0 7So i set u r€,.." X - <br /> VII.Raspeegibilly fit-I,tie adtwsigaed,asses respsssibility kr antalsten stile POWis shawls as the atanbei pins. _ <br /> Mesa's Name(Pr 0 a Sipa ate Number Badness Phos Number <br /> TO F. T i- r" !-U� . .�--. d a 3 `a? 7 6[4.0�� `r6, 7-9. 3go <br /> Plumber's Address(Street,cy,Same.Tap Code) r <br /> 3,U`, j9eic..--.5 5r. /4'114�c.li t c.✓ I • 5 35 iq <br /> VIE Comity/Department The Only <br /> 0 ed Pmt Fee0 Date Issued Ag <br /> 0 Owner Given Reason for Denial $78g— `l z I - 09 ent - l ��� - <br /> IB.Cotsditione of Approval/Reagan for Disapproval <br /> ------, Y -. &,G,/ T S; ,'i/- /'C,161(7 ft 41 <br /> ANNA to amide ph=tier ale gig=ada lbarthe County M4at paper Not tam bre SeraxllWmis she <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />