Laserfiche WebLink
the Department of Safety and Protessronal Darns_ l'txmonal mmnnaton you proviue may oe uscu ma s uuumy 0 <br /> 1 Ids ' �Q.4 <br /> purposes in accordance with the Privacy law,s.15.04(IXm),Star ! L <br /> L Application Information—Please Print AII Information <br /> Property Owner's Name Parcel# <br /> TitMU7"41y i ILA ttuEnt CLAZ AN C10 RACNIC71 ALEkArliOER, 0(12,( C) - O1'7 2- 9000-3 <br /> Property Owner's Mailing Address Proms Location <br /> 3.45 W. vjA51..tiki G,TO A EI k4s1 S4 1TE. 30 1 Govt Lot <br /> City,State l, r Zip Code Phone Number S W 1/4, ['W i/4, Section 7 <br /> IAAoksor.) `N I 55310 3 T (.o N; R i o E <br /> IL Type of Building(check all that apply) Lot# <br /> Number of Bedrooms 3 Subdivision Name <br /> lar2 Family Dwelling— <br /> Block# MC-1-ES �coD 8tet.t')uS <br /> _ <br /> ❑Public/Commercial—Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned—Describe Use rgi Town of D umi.1V <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ❑Replacement System AT. <br /> Treannent/Holdmg Tank Replacement Only QOther Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber permit Transfer to New t�� 5� �` l 5���7.GI!� <br /> Before Expiration / <br /> N.Type of POWTS System/ComponentlDevice: (Check all that apply) (( <br /> Non_p In-Ground 0Pressurized In-Ground at-Grade QMound>24 in.of_suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank E ^Dispersal Component(explain) Dent Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Flow(gpd) Design Soil Application Rame(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> $O o-y t1z5- tt e `1e3 1 q7s- <br /> in Total #of Manufacturer <br /> VL Tank Info ^ <br /> Gallons Gallons Units a 2 U e <br /> New Tanks Existing Tanks = q 0d .0� d <br /> ec <br /> .U <br /> ET, m rr) w 0 a. <br /> Septic ielding Tank Pig c>/i ! .e-z c_ <br /> Doting Chamber 4(6 1 -- - y4., 7 /' _ <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the PO'R'TS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz 1.), 220165 608-831-8103 <br /> — <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIIL County/Department Use Only �/ <br /> proved ❑Disapp.oved <br /> Permit Fee Date Issued lss�ting ." ') w//`ICE ^' <br /> `� 6-q-2Ws- , 4 _G11 Y <br /> ❑Owner Given Reason for Denial { l�. Y <br /> IX.Conditions of Approval/Reasons for Disapproval c i\n _/ '( C,r --ra---( ,E- r .,,r Q- / <br /> a 727w(Lp(M . f r"Ec r 7o ut' - A / ' _-. e �'S <br /> cgrVtl( B if(A7 Ar xse to ffm T 0 t/ a° /(7 l ati carztor <br /> Attach to complete plans for the system and submit to the Comity only on paper not less than 8 Ui z 11 inches in size <br /> SBD-6398(R.11/11) <br />