Laserfiche WebLink
• Oct. 12. 2009 9;091AIN1 [' Ih II �V/ It No. 1487 P. 1 <br /> commerr �nli.gov Sa` d Buildings Division County <br /> tisco I t■ ci " 7 2009 W gran Ave.,P.O.Box 7[62 rte M o t,\V1 53707-7162 —' <br /> Sank Nfry Co.) <br /> Department•I Co melee <br /> �._�,... _ y._ <br /> ' Illlt'2 a,1� se )lJ a ii ion Stoe Transaction Number. p — <br /> In accordance with s.Comum.8121(2),Wis.Adm.Code,submission of this fort to the appropriate governmental Ake i 6M �� <br /> unit is required prior to obtaining a sanitary permit. Note: Application fors for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with dre Privacy Law.s•15.04(IXm).Stets. ,� <br /> T. Application Information—Please Print All Information 17.t eg 11-6' <br /> Property Owner's Name Parcel t <br /> SSe.e-1 LWAitikierc.ort _ a-1oS-- c ii- 15z__ <br /> Property Owner's Mailing Address Property Location <br /> 726 v` CA , ■n�.[ ()rt14- 311 <br /> City, tate <br /> Govt.Lor <br /> ry Zip Code Phone Number NE VI, Section <br /> to As.c-n I/,1 "1 Y7 (circle one) <br /> 11.Typo of Building(check all that apply) Lot N 1 7 N' R 8 f • <br /> NA or2FamilyDwelling—NumberofBedrooms 3 .3 Subdivision Name <br /> Mock 4 y ttti L- <br /> ❑PublicIComnicrcial—Describe Use <br /> ❑City of <br /> - <br /> ❑State Owned—Describe Use CSM Number El Village of_ <br /> tTown of M1l M iettl\ <br /> III.Type of permit: (Check only one box on line A. Complete line B if applicable) <br /> A- PLIsfew System Y ❑Replacement System ❑'freatmentJlioiding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B- ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Peril Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) _ <br /> IXIJon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) ' Dispersal Area Proposed(sf) System Elevation <br /> '-lx� .FF �. 1,12 r � <br /> `l l 8-sr—fit oI <br /> VI.Tank Info Capacity in Total 4 of Manufacturer o <br /> Gallons Gallons N <br /> New Tattles Existing'fanks a gg gg <br /> . r. <br /> Seploor#oldttgTank (G]] +CCC i M' (e K Dating Cheraw taGa p i I Le- <br /> VII.Responsibility Statement-t,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans, <br /> Plumber's Name(Print) Plumber's Signature '-MPIMPRS Number Business Phone Number <br /> rr!(tW W• Nhtnhd2 ,`_-. t ry , lC 20(-S103 <br /> Phunber's Address(Street,City,State,Zip Code) <br /> eaSl Crt-i- K WG(4t4-44tGt_, I/..)1 5 `7 <br /> VIII.County/Deparlment Use Only <br /> Approved Q Disapproved Permit Flee Date-issued Issuing A Si ' c ACeosr___ ,_. <br /> U Owner Given Reason for Dcnil ..3(Qt1 •---- P---g-9 <br /> IX.Conditions ofAppror I/Reas�on for Disapproval <br /> — S, f4J7f ✓rY i' wA- — ( fr,41(/f}'r f-7 /‘:'444/ <br /> D13 —— Attecd ro complete plane for the system and submir ro the Canary only on paper not less dean b nix 11 Inches In eta <br /> D <br /> 13 )173 <br /> DA- 5-3ao1 <br /> SDD-6398(R.02/09)Valid thru 02/11 <br /> • <br />