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' comi1l rte.Ml. V Safety and Buildings Division Comity <br /> 201 W.Washington Me.,P.O.Box 7162 iA E. <br /> Iscons n Madison,WI 53707-7162 sa>nitary Permit Number(to be filled in by Co.) <br /> V 57503L/ <br /> Sanitary Permit Application State Twans ronNumber <br /> In accordance with s.Comm.83.21(2).Wis.Aden Code,minnissioe of this form to the appropriate governmental <br /> uric is required prior to obtaining a sanitary permit Note: Appli -_ . - • . ,_j. :AWL'S awe Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information I L e `"' E u d U w!� �'^1„w,.• in accordance with the I'riva Law.s.15.' 1,m, Stater. <br /> L Application Information—Please Print All Information I -4 MI Parcel it • <br /> Property Owner's Name <br /> 0 O V 6-(<- 2%w. AA_V__i?d+/k A 1 1 JUN 2 3 2008 II n i i — 14 ( ��c a <br /> property Owner's Mailing Address ( Property Location <br /> 3.q e: i &A 1 Le`r Pur lIG Health l'ADC <br /> City.State Zip Code —•,s`L'-... - ` •- '-'-•'=t.i 1 A) y 141 L K, Section r� <br /> 5 u.�-J PRA L r2 t E LC.+--,/ ••53 S-10 d7} S ” 3' L T it R 1 ( E <br /> Ti.Type of Braiding(shack all thtit apply) L. Let ft <br /> Q'1 oar 2 Family Derailing-Number of Bedrooms 1 _ ) Subdlvjsion Name <br /> Block# <br /> ❑Publie/Commeruial-Describe Uwe_ ....--_, ❑City of <br /> cam N <br /> ❑State Owned-Describe Use �_ mabet ❑ Village of <br /> 1 41 i b ®Town of '-'-,- Pa"1.�r e <br /> 111 Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> 'L ❑New system U iii alcement System ❑Treatment/Holding Turk Replacement Only ❑Other Modification to Existing System(explain) <br /> Li <br /> R. ❑?aunt Renewal ❑ Permit Revision ❑Change of Plumber Q Permit Transfer to New <br /> Before Permit Number and Date Issued <br /> Before Eamon Owner <br /> IV T i• of POWTs s . , ,i Coro.. ,ent/Deviee: Check all that <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑Ai-O adc Mound?24 in.of suitable Boil Old<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. I. . rss]ITreatmet t Ards Information: . <br /> Drip Flow(gpd) Design Soil Application Rete(gpdef) Diaper set Area Reip iced(st) Dispersal Area Proposed(sf) System Elevelion <br /> (v, e .• . l oa c5 f s. I S 4?".0r.E ' <br /> n Tank Info Capacity <br /> in Total #of Manufacuuer <br /> Gallons Gallons Units �C,g S I <br /> New Tanks g ` ° ' 9 w <br /> (iii. r0 Chtenber IIMMIll 7-1") WM G-lQE. 1 1011IMMI IIIII <br /> VIL ' - ,oelsibiilty Statement-4 tilt undersigned.assume • • ... 'qty f•s., - •' ..a of the PO f,,;, , an tae attacked pions. <br /> Ito'c Name Plumb& r' PRS N bw rasa Phone Number <br /> . ..JO el ilLi f. A ,r i -�' Z Lr� •`� alter <br /> Plum.-'s Address(Street.City,State.Zip CoAfill =Pr _ <br /> -�:.. A % 1 r KO. ft a SoA) _ £.. .S 8 7/3 <br /> ' II o 1 ::lJ, nt Uses fianr <br /> Permit Pee Dare Issued •1 = -'�/,�, <br /> ��„Lprwed El $ � ? <br /> t <br /> ❑ Owner Given Reason for Denial .•r i•f�3 + /� �_' . •+ate <br /> Lt Conditions ofApptvvallReas for Disapproval ! r erk to..sci_iii. rmis, ' <br /> or <br /> ail -° ,.. h.,--- Atel.(14.,-(2f-"et d . A <br /> Attach to complete plans cur the and manta(to the aly only on paper not tar then 5 VI ill Inches w else <br /> SBD-6398(R.01/07)Valid thru 01/09 • <br />