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C-3-2e:21 <br /> ="...0I indusny Sersric ea Di visiim County <br /> .4..', I 400E Washington Ave OA <br /> i:r*:.... Sua p. .7,.. P.O.R 7162 Sintary Pennil Nunhal(to be 1111.4 in by cri:i-' <br /> . Madison.wi 53707-7162 <br /> /3 -7-021—DO 1 560 <br /> ..... .... <br /> Sanitary Permit Application Stale Transaction Numbs7 <br /> 1 <br /> in aceorriasze.with SYS 283.21(21.Wis,Adin Ceik.anhiti“inn Milli%form to the appropri-lefpqtanwittAlunh <br /> tet(ttirctl Fr ut to nbtalaini a uniari.prmit.Note:Appikatiun farms.for ti c.1 PtliN'TS arc submitted m Pridcat Address(ii different than mailing addrecti --1 <br /> , the Deponment of Safety 0.4 Profeaainnal.S.,:viCCA.Personal infonration:,ou pro,ide may ha ttud for sece ,. • I <br /> _pitrpiyeLin acconianze with the Privace Law.s.15.0.1trintl.Start- rfltp• €511,4 OFF 1. <br /> . -. <br /> L Application Information-Please Print Ali informati --- <br /> on .i 710 (Cf:14: 1 A ILL (3•J <br /> Propert)On her's Naino Paled• <br /> VCA:4%.,E:V.,-; Al(..-i1.--. c—i..00 1c <br /> Propmy(),Val's)4.4d <br /> ns Adrei 5 — Property lAs.rion <br /> ,A-4"J'./4' 1-317.TE: <br /> •City.S13 'Zig Code !Phanz Nir-inber <br /> F..i./4“ C..ni-'k5-\i o..:1‘ ;ti.... ,,,ic (eirele one) <br /> I <br /> _ 7 t:L Tyne of Building(cheek all that appW T N. EuMV— .of e <br /> or 3 Family Dwelling-.Number of Redronnts '} Subdivision Name <br /> litecli o <br /> OpublieCommodat-Describe Else <br /> 0 City of <br /> CSM Ninety'. <br /> D Stale tjuned MM.rle l(se 0 Village of <br /> t e.i k a i Alk <br /> PP <br /> .iP. <br /> 6.est-A <br /> tn.Type/Permit: (Cheek only one bon no line A. Complete line H if applicable) <br /> it.. „... <br /> KNen.Systrm 0 Replatvnext Systoh 1 0 Trratmenel Mding Tan::RepIxtmtat Only 'U Other Mudifonnon to Existing System fraplaint <br /> reveiniandluir 1..yikeil <br /> I-I Pernit Renewal 0 Permit Revision I 0 Change of Plumber 0 PenuLtin Pious Por Nr <br /> it Transfer to New <br /> Bert Expiration <br /> I •Chaves <br /> IV.T$i a Of POP.TS SystemComponent/Devitt: (Check nil ghat apply) 114J1- 334A-11:/--a:-I Ei ' <br /> 1.3 Non-Prystatrizet1 lo•Ovoind 0 Pressurized IneOrounil 0 At-Grade Ercitxtnal tt 24 in.or re:table soil 0 Mooed e 24 in.of thilahle soil <br /> 0 i lidding Tank 0 Other D is pesalComponent(captain) Dr.:taw:a:at Device(explain) . -- <br /> . ., <br /> I'.his •rsolfrreannent Area Information: ! <br /> Design TTio.'(god) l Design Soil Almlientn RatOgpilsf) I Disposal Arno Required($11 '. )ttperial Area Proposed ixt) I System FIValiOil <br /> t'.-.L- PNSAS'ij14>Z411 I 1 121,1` '470 1 4.7-...%"/C'e)e.) 1 C1/11 1 <br /> VL Tunic Tufo i C000eity Total -.of Manuticitubt <br /> Gallons Gallotts Utiltt ; ii t.'2 .t.i <br /> tot; <br /> "?,U FR0. I 1 4 1 <br /> , aka.Taol:s fix.:tni o <br /> tii 100 Ir. <br /> SZO:i or Itoldiez Tank i .— <br /> 21N..... 1-4-‘1 '' triCitYll.". <br /> t .rie) ( NIC:i'l.t--; -.1.,I <br /> ... ..._ <br /> VT!.Responsibility Sintemeni-L the undersiontil.assume responsibility fur installation of the POINTS shown on the attached plans. <br /> Plumber's Name{Print) I Plumber's Signature VI ,. I 44P.N1PRS NUItiber I Radium Pheiric Numbri <br /> ca,.1.- N.k4ioi ..t.... I 9‘Ve'‘‘..-" <br /> Plumber's Addreet 4Sturct.City.State,7ipCodol <br /> (-P( 1-.1't V, I;\JA.t.;L. i.14'4.;.,o...\i . ..1) .. <br /> vm.Comairlhpurtmeut Use Only "pro(i-p/r)...e6'—3--za.,7,.../ 1 <br /> Pennit Fec i {rhtc Issued <br /> !at'Appnwrd 'D nkapproved <br /> s t36D 1 ti'lit/).01 I <br /> I tutting Agral SIgkraUur„.1 , 1 <br /> I <br /> ,0 Owner(liven Reason for Denitd <br /> I TX.Conditions of ApprnvallRensons for Disapproval/ <br /> Protect&Maintain:,14 Mound/D At-Grade site and 15 feet downslope in its natural <br /> condition. No compaction, excavation,disturbance,or vehicular traffic allowed. <br /> 4?1, <br /> Ensure tank locations are within 150'tn all-weathekrinse,rvmiceechpaandicsanniduwsittbhein,lr50'vvideertdicialedxceepetdhed <br /> difference to all-weather service pad-S.eci k sery . <br /> sno-6398 ot.ttb/14) <br /> If lot lines for proposed CSM once lot lines finalized result in any septic system components <br /> being off lot from proposed residence, easement will be required. <br />