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. <br /> . <br /> r g o a a <br /> t 4 , <br /> lAitti.S--ttPTIC=PttlMg!ti PA ---Z c,=. `T <br /> ititnleao ad asallsaa• - <br /> dell till-sego Nesslises•t4 Om siol*...,rues ., <br /> > -scowsatyrii e <br /> !o ACRES . tIzusla.U$-rsatdeimam <br /> Me 4Ya-gel-Pamir nwlig j 4, <br /> III AlJflf•if�t. hctsss•g/+1Ua Waft Kt - M t" L- <br /> jANgGaGII Foes; W <br /> ., Industry Services Division I j <br /> i f . 1400 E Washington Ave —_—_____.___1'T_ <br /> �� r' ;r P.O. Box 7162 �yu5) < Sanitary Permit Number(to he filled in by Co I — <br /> <,I Madison,WI 53707-7162 " fir <br /> i <br /> "'f`+rim'.:�• �O <br /> , <br /> Sanitary) Permit Application Sc ta IransacUnnNumber <br /> In ateordance \\101 SI'S 310 21(2). Vin Adm Code submission of this form to the appropriate goscmntenkd unit 3- J 0I )--- 000-7 q • <br /> is required prior io obtaining a sanitary permit. Note Application loons for state-onned POWT S arc submitted to --- I <br /> tin Deparmunt of Salo) and Professional Sets ices Personal information sou prosidc nru■ he used fni secondary Protect Address illdiilercnt than mailine address) <br /> purls s s in accordance oith the Priyacs Lass s 15.04(I)(m)_Slats ,,D sort( ii(g/%;., b <br /> 1. Application Information- Please Print All Information Wf 7 e Le-)7..r��'it-' <br /> Propem Owner s Name Parcel r — <br /> 3/ C/V be9%�!`/ 7�1J�`;'i. X5`3 _9f�© � <br /> Pu>prits Oscnet's Mailing Address Ptopeny I°cation <br /> _ g 3Cf 1-L.1/' AL V, L% I Grist Lot <br /> ('its.State Zip Code Phone Number I U S(..(J';.. Section i2-1-/ <br /> U)/177-:-P-7./7C) L1)/ .7.-399 /- (ci le one) <br /> / / , T `� N /s9,, R r N <br /> 11Th pe of Building(check all that apply) I.ot a _ <br /> NI or 2 family Dwelling- Number of Bedrooms _-- Subdivision Name <br /> ❑ Public/Commercial- Describe t!sc Block ti <br /> ❑ Cite of <br /> ❑State Owned- Describe Use ID Village of <br /> CSM Number <br /> j;1/-70 i Town of yfjZK <br /> ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A lo' New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renessal ❑ Permit Revision ❑Change of ❑Permit Transfer to Ncsc List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System/Component/Device: (Check all that apply) _-____ <br /> ® Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound 24 in.of suitable soil El Mound<24 in of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> i ? Rate(gpdsl) O. 1/ � II `S, Wa/g9`3 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of t el 0 `? <br /> Gallons Units Manufacturer o 2 u a a <br /> New Tanks Existing Tanks c V . v 7: i.C.t. 0. <br /> Septic orNetdutg Tank C la-2.2/2 SL.) `-- /C('1) / I iv/.hg ...__ ® ❑ ❑ ❑ E <br /> Dosing Chamber _ II ❑ ❑ ❑ ❑ E <br /> VII. Responsibility Statement- I.the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb r s Signature MP/MPRS Number Business Phone Number <br /> Ip S ' ! At - Li.==, ,1¢-.m, - ' 90/ 7c7t `jam 7S)'-'.;1319 <br /> Plumber's Address(Street.City,State,Zip Code) <br /> r mjrA' '• <br /> N 3�'S S'" (fcV /..7 FLO"C) r (_)--)ii-r2 %=,�LG`N5 r LJ t 5"''',a 2/�. <br /> VIII. Count '/De artment Use Only <br /> - r ---r r . <br />