Laserfiche WebLink
1 _ 1 ■ f' <br /> I <br /> commerce vu%gpv Saf==y d •:ildings Division County <br /> 1 L I !_ �01 9Vas 1 i `Ave.,P.O.Box 7162 �A r-�� <br /> rc�O� �n Madis . i 53707-7162 Sa a 1 by Co.)epartmerttaf trnet4 -i-u6Tc Health MDC <br /> Sari • ' .3- I i i f-It . . - . ;1 II State Transaction Number <br /> In accordance with s.Comm.8321(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. C-T-1 L S <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel At <br /> ' 9 1-LL—J 3(Z 19 PIP bt-t'2-- N ( - c7- o — a <br /> [Property Owner's Mailing Address Property Location U <br /> /o )l LZ LD t-. l j.,).B M, 2G 6 o G .7 `� ��, 1 l <br /> City,State Zip Code Phone Number �� '�<, Section <br /> V 4)t-04-e c...,--,1 _ �s`7 3 C of#J�`f�- 7 ye . T L N; R 7 E <br /> II.Type of Building(check all that a I . <br /> ['I or 2 Family Dwelling-Number o : ..,ooms Z Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> El City of <br /> ❑State Owned-Describe Use = 'Number ❑Village of <br /> b 3`-i Town of 5-P(2u-s 6-D A Lc <br /> HI Type of Permit: (Check only one box on line A. Complete '. B if a 1 'ii • <br /> A' ❑i S stem ❑Replacement S <br /> y ep 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 <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground [-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 Flow(pd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 6e,- o.c._ / d I -z.,=.o 47_ a <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a 4; tr. o <br /> New Tanks Existing Tanks o N i y 2 Q at <br /> 4U vs a' rn w0 F. <br /> Septic or.I eldmg—Tank 13 c, — 13- i DALMARAY X _ <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) . Plumb 's Signature PRS Number Business Phone Number <br /> TIMOTHY JELLE 227-525 (608)845-7466 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VERONA SEPTIC AND EXCAVATING,501 COMMERCE PKWY., NA,WI 53593 <br /> VIII.County//Department Use Only { <br /> `Approved ❑Disapproved <br /> Permit Fee Date Issued Iss g�:.3� ► ' ' <br /> ❑Owner Given Reason for Denial <br /> g08. 7/ a/ �•�►! '4�,' (Z 5 . <br /> IX.Conditions of Approval/Reasons for Disap proval <br /> O CON <br /> TY q itc 64ei u "sf 6I�!i V' 1.6N H I HIS APp,. �v DANE-- C-31111.-A65071-W <br /> Mr[vv(-"tRONMENTAL HEALTH DOES NOT HOLD ITSEL <br /> LIABLE FOR ANY DEFECTS IN PLANS OR SPECIFIC <br /> Attach to complete plans for em and submit to ttie Com o T' F i r,l'' . .cis"), `A1 M1 NATTO N OVER- <br /> P P �Yn ty only on paper not less t�ar;'g'rh ri1`t�xl�i>br3i4e <br /> DB A11 ( SIGHT. C�:+NS i RUCTION OR ANY DAMAGE THAT Mi <br /> 1 �J ^ IoZS O RESULT'.N OP AFTER INSTALLATION AND RESERVE <br /> SBD-6398(R 01/07)Valid thru 01/09 THE RIGHT TO ORDER CHANGES OR ADDITIONS <br /> SHOULD CONDITIONS ARISE MAKING THIS <br /> NFrCeceov <br />