Laserfiche WebLink
".: � <br /> -\ I <br /> commerce.4►i.goV v Safety dings Division County ((�� <br /> 201 W.Wash ngton Ave.,P.O.Box 7162 b011 l <br /> i s c o n s I I 1 ui iic Health M n,W 53707-7162 Sani t e (t belle n by Co.) <br /> Department of c«nmerc¢nviro t�mental Health <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <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. 15.04(1)(m),Stats. /�/���N / Ql/r J <br /> I. Application Information-Please Print MI Information /�/ Q' r' <br /> Property Owner's Name Parcel# <br /> rq i DVd-{ C)-717_— 3 3-6iS —0 <br /> Property Owner's Mailing Address Property Location <br /> 27o1 C/eA,V(ew Pid• Govt.Lot <br /> City,State Zip Code Phone Number kb: '4, g AAA, Section 3 3 <br /> 2 91D-3, circ, • e) <br /> awl,n d t&) Z3 7" O/Oc T 7 N; R GP W <br /> H.Type of Building(check all that apply) 1 <br /> / Subdivision Name Lot# <br /> ,G <br /> Al or 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of . <br /> -r CSM Number ❑ Village of <br /> ❑State Owned-Describe Use <br /> ' J7 ( 1 iti Town of bee ci e <br /> ' [II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. la New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other 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 <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 64 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 is of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersalareatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> W SO . 'i Il ZS" --ittrii 50 71V. 3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ;? °-" `0 <br /> U <br /> .0 U U V �' in <br /> New Tanks Existing Tanks o E :? a `-° La <br /> P, U b ; en w t7 a. <br /> Septic or Holding Tank ,;67, I'Z,/rA f b•t Irks wra/ CIO/f?i,, A. <br /> Dosing Chamber /"" <br /> VII.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 IV/MFRS Number Business Phone Number <br /> Tegviy I Ltvakc yyr,7 ZZ 33Zz 920-989-756`7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Pd. gox 4g- h ke fi1 /% WI S35-4- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Iss;44- <br /> PProved ❑ Disapproved SJ F -- t c 216 / i/ s it.0 <br /> • . <br /> ❑ Owner Given Reason for Denial � i <br /> IX.Conditions of Approval/Reasons for Disapproval ;.; k.; t,...:vTI‘!O i HIS APPROVAL, DANE COUNTY <br /> ENVIF-VD "rS".NT'','. LIT: .I_7H DOES NOT HOLD ITSELF <br /> LI'ri' FOR ANY DEFECTS IN PLANS OR SPECIFICA <br /> TIONS. PLAN OMISSIONS. EXAMINATION OVER- <br /> S''3HT. CONSTRUCTION OR ANY PAMACF THAT r,L1A1 <br /> ach to complete plans for the system and submit to the County only on paper not less thatfiiL-.l.t ll lriti iev{tspkI-TER INSTALLATION AND RESERVE; <br /> D�� a�� THE RIGHT TO ORDER CHANGES OR ADDITIONS <br /> SHOULD CONDITIONS ARISE MAKING THIS <br /> SBD-6398(R.01/07)Valid thru 01/09 NECESSARY. <br /> ChK— 5 3(1 0 :; <br />