Laserfiche WebLink
" "'__. _. <br /> `' 10/12/2009 13:39 FAX 2625604795 <br /> OMa1leyEom � ..... <br /> =_ "„ 2001/002 <br /> ii"-i), 1 U I , <br /> •-[ com ie s. .igov w. :l '. Buildings Division County <br /> a 11 • CT n r�,gton Ave.,P.O.Box 7162 �ye <br /> I 5C0 In 0 ,WI 53707-7162 Sanit• ..:- o - . .y Co.) <br /> Department•f Co merc e Or f - <br /> a an� , a 6tetcTransaction Number . <br /> nit•4,11 en>jt-1-•• i ,lic. . ion 7 � <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental J7Ailte 7�t (( "O b/ <br /> C) <br /> • unit is required prior to obtaining a sanitary permit. Note: Application forms 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 the Privacy Law,s. I5.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information Wb'Y 7-1-4 61 <br /> Property Owner's Name Parcel# <br /> ,1SSe.`l L'lezi'c bierscrl _ _ 01275-- (3G-4--• 152 -0 <br /> __ <br /> Property Owner's Mailing Address Property I.ocation <br /> 72(, " atak,4 0-‘14.-- 31 <br /> Govt.Lot_ <br /> City,State Zip Code Phone Number <br /> NE v.,. '/,, Section/ <br /> N '1 (i 1 5g-1 ri _ , (circle one) <br /> T 7 N; R 60 e <br /> II.Type of Building(check all that apply) Lot# <br /> WI or 2 Family Dwelling-Number of Bedrooms '3 .. Subdivision Name <br /> Block# iRecKy E).4 I <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> CI State Owned-Describe Use CSM Number ❑Village of <br /> "g Town of M.t l let6K <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. FNew System y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Ion-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.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> `t . "r _ .4-5r: 026 4=PZ 113-1 .13- '- ‘1(.p' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons _ Gallons Units P. 5 <br /> New Tanks Existing Tanks o U <br /> ` o C.' .888 2 2' <br /> _ r,,, R. U in . rn iz• (7 p., <br /> Septic on+lol ig Tank 1 a•0 I r (s' e Le <br /> Dosing Chamber tad — 7 <br /> 1 'it <br /> VI1.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature -1.P/MPRS Number Business Phone Number <br /> 'L(ie.A,v J' WA-rt►,012- `.--..{N.a_____ I.L.)_- )- 23!%1( es3I-S 103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> X0813 CT4-4- K AfrALA tea. ec-. W( E/ '7 <br /> VIII.County/Department Use Only <br /> ill <br /> ,.roved ❑Disapproved Permit Fee Date Issued Issuing A0 Si: . re <br /> ❑Owner Given Reason for Denial <br /> $301 .---- t° c-' /(4.4.44Nr...... ...._. , <br /> IX.Conditions of Approv VReasons for Disapproval <br /> DB - Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x II inches in size <br /> a773a <br /> C K- 53a01 <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />