6940 Lumberjack Trail Danbury, WI 54830

                         aomrrmree. wi. gov                                     Safety and Buildings Division                          County
                                                                         201 W. Washington Ave., P.O. Box 7162
                                               a
                                                                                                                                                     IAri
                                                                                                                                                      r   8 7
                                                                                 Madison, WI 53707- 7162
                  iseonsm
                  oapa, u, hmmt a
                                                                                                                                       Sanitary permit Number( to be filled in by Co.)

                                                                                                                                       State Transaction Number
                                   Sanitary Permit Application
 In accordance with s. Comm. 83.21( 2), Wis.
                                                     Adm Coda submission          f this form to the appropriate governmental                                                                     1

 unit m required prior m obtaining a sanitary permit Note: Apptikation forme for ehto-oowned POWTS are project Address( ifdifferont flan mailing address)
 submitted to the Department of Cemmefee. Personal int'omutioa',.you provide may be used for secondary
         ea in accordance with the
                                       Privacy Law, a. 15. 04( 1)( m, Stats.
 L Application Information- Please Print AN Information
                                                                                                                                                Ay      fh       LA
                                                                                                                                                                           AA
                                                                                                                                                                          Q•
                                                                                                                                                                                             C3
 Property GMmr' a Name
                                                                                                                                       Parcel# 07' oZD- 2• rlD• IL• 03. 3 o/- oC0• o170Uo
         Rand

           S IS
 Ciry, State
                             AIA V en
 Properly Owner'a Mailing Addicee
                                    d/!/
                                                                  Zip Cade
                                                                                                    A

                                                                                               Phone Number
                                                                                                                      4                Property

                                                                                                                                              Lot
                                                                                                                                                          0_
                                                                                                                                                        tim
                                                                                                                                                                    y3o3 - Oj7/5—


                                                                                                                                                                   y. Soon
                                                                                                                                                                       w            3
         ene      P;(/   e          An   IV
                                                                  SG 3d.
 IL Type of Building( cheek all tint                                                                                                   T     Z/ O
                                                                                                                                                     N;      R       cockor cl.,7
                                                   apply)                                      Lot#                                                                      BV
      1 or 2 Family                Number of                                                                                           Subdivision Name
                       Dwelling-               Bedrooms70
                                                                                               Block
      Publi/ Commercial- Describe Use
                                                                                                                                           Cityof

      State Owned- Describe Use                                                                CSM Number                                  Village of
                                                                                                                 378 M5

                                                                                                Vol 415Town of
 III. Type of Permit: ( Check
                                         only Dere box on tine A. Complete tine                  if applicable)
 A.
             New System
                  ye                     Replacement System              TreatmmVHoWiog TadcRopLcem® t Oily                                Other Modification to Existing System( expIsin)

 B.          permit Renewal              Permit Revision                 Change' iiof Plumber               PermA Traafcrto New     List Previous Permit Number and Date Issued
          Before Expiration
                                                                                                       Owner


IV. Type of POWTS S tem/ Com                        mt/Device: Check 4 that apply)
      Non-Pressurized In Ground             Pressurized In-Goin              At-($mde            M— d> 24 in. of sud- bk soil              Mond< 24 in. of eaa ble soil
      Piolding Taolr         Other Dispersal Component( explain)
                                                                                                                     Pretrwtment Device( explain)
V.          rsaVl'reatment Arm Information;
Design Flaw( gpd)            Design Soil Application Rate( gpdat)          Dupefsa] Area Required( at)                Die PersArea Proposed( at)             System Etevation
       3 0p                                    7                                        NA9                                L/ Sd
                                                                                                                                                                 y(,
VL Tank Wo                                      Capacity in                            Total    #      of               Manufacturer
                                                   Gallons                         Gallons          Unite
                              New Tanen                ZugTampa


Septic or Boklng Trade
Ilovrig Chamber


VII. Reapo hipfity Statement- f,the undersigned, assume re
Plumbcr' e Name( Pon /
                                                                                       si