Laserfiche WebLink
II. Sep. 28. 2009n10:44AM .... t is ii u ..z -- hilttidingsDivision — County No. 1411--�P, 1 <br /> 1 .�+/+ 201 Ave.,P.O.Box 7162 N <br /> �i�7�ron �'� C �t ' 53707-7[62 sent f ti <br /> Department of Co r - SEF 1 4 20 <br /> n y, r r : ti! n State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis. :..r ? j ;i�j i� j'!l'�, is form t the appropriate governmental � � VCS�� <br /> unit is required prior to obtaining° ^"^i• , =f�l xI!:'"..R <br /> �� - .n-€erns for state-owned POWTS are Project address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal informatio you provide may be used for secondary <br /> u in accordance with the Privac Law s.LS.04(1)(m),Sons.. _ '-r <br /> 1- Ap.licatlon Information-Please Print All Informatin 5ARACeit/ W p t1 <br /> Property Owner's Name • <br /> 04>I �Illlnl� Parcel# <br /> TTraufsri_TO",ATMo - E�ehMevr 038'1 0708-323-65 YS ) <br /> Property Owner's Mailing Address Propen Y Location <br /> q524, S /YF ie arm a.,g L1.J Govt.Lot <br /> Ciry,State Zip Code Phone Number / <br /> se '/,.St,! %, Section 3 Z <br /> ll J 1!E4O it I 3395 (circle one) <br /> H.Type of Building(check all that apply) `Lot g 1 T?N; Rbr w <br /> 13-117:-.2 Family Dwelling-Number ofl3edrooms 5 Subdivision Name <br /> Block/! G LAGrees a 0 0 CIS <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> JP' C 'awn of /' /14) ig r� <br /> III.Type of Permit: (Check only one box on line A. Comp tie line B if applicable) <br /> <w System ❑Replacement System ❑Tree •nt/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision El Chang.of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration <br /> t Owner <br /> IV.T .e of POWTS S stem/Com tonentfDevlce: Check al that a..I <br /> l: on-Pressurized in-Ground ❑Pressurized In-Ground ❑At rade ❑Mound>24 in.of suitable soil ❑Mound<24 in-of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) <br /> _ ❑Pretreatment Device(captain) <br /> V.Dis■ersal/Treatment Area Information: a 2.-4..a. fte - t, air- 4 Cf J <br /> Design Flow(gpd) . Design Soil Application Ratc(gpdsf) Dip• rsal Area 'equired(sf) Dispersal Area Proposed(sf) System Elevation <br /> V T Tank Info 1�ODirr �93•D --g2, <br /> Capacity in Total k of Manufacturer <br /> Gallons Gallons Units Qb <br /> New Tanks Existing Tanks 0 ° 4 <br /> fz+3Q y V ta.3 F. <br /> Sie is amtletdin Tank <br /> L1 V <br /> Dosing Chamber <br /> 30D 2400 Gt1/Q � folY�(C Fir{Q <br /> VII.Responsibility Statement- L,the undersigned,assume reap.risibility for Installation of the POWTS shown on the attached plans, <br /> Pumber's Name(Psi t) Plumber's Signanir. MP/MPRS Number Business Phone Number <br /> 14 1 cl ..eL a r ;�J� r--74,1 ey. wZ, <br /> PI bet's Address(Street, ity,St , ill ode) 13'u -1 c "va & dG (1 7 S <br /> VIII.Coon /De I artment Use Onl f ``' <br /> A approved ❑Disapproved <br /> Permit Fee Date Issued lssuin: ent ;nature <br /> ❑Owner Given Reason for Denial $JI0a ��`Ce— e / < AteaNr- <br /> IX.Conditionie of Approval/Reasons for Disapproval <br /> 164-resv" $ECG?2t r /,sue '‘. Fr 6.4£4 <br /> —i rot Pow-tf O&.w(,a r /''Nwre- f . -r <br /> • <br /> (L 4 ft 1hw l- PRN/1.PC oc - EyQ wry'( fEf rc rMvic effimovi Fir.? ( <br /> An`eeb to complete pions for the system and s broil to the County only on paper not less thin s in a II Inches in stye <br /> D -- 2 T7 rr 1 i <br /> SBD-6398(R.02/09)Valid thru 02/i I ^ <br /> np ; rN .AL <br /> 1 <br />