Laserfiche WebLink
Aug. 14. 2009 9: 16AM No. 1140 P. 2 <br /> it � V E <br /> . Is' .: <br /> commerce-wl-y v 1 Safety and B IT':s Division Coun <br /> �a <br /> 201 W.Washing, Ave,I'.O Box 7162 t -- <br /> iscQnsi� ublic Neap r 1,4, . ' L 53 7-7162 <br /> Departmont of commc rca En,-rotlrrlerl i Health ,._ <br /> Sanitary Permit Application Sate Transaction . <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental pA� ��'"r 1. b / <br /> unit is required prior to oblalning a sanitary permit. Note' Application forms for stale-owned POINTS arc Project Address(if different thanmailing address) <br /> submittal to the Department of Commerce. Personal information you provide may be used for secondary FAR V V/(E� <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats- _ f/'trC <br /> L Application Information•-Please Print All Iuforurnlion <br /> I'roperty Owner's tram Parcel if <br /> `fiats►dl 1 eszg oq--Ida--CiOW.S <br /> Property Owner's Mailing Address � Property Location - <br /> •au J l �! •4 c a_ _ <br /> tki- • 1 to cow.La1 <br /> City,State Zip Code Phono Number V4. (J , <br /> b <br /> SW , {� ,Section 1 1 <br /> -- e2 4.e, I __:.,,c....w,.'. 9-eft ^3t11ta Cairo Pane) <br /> T N; n '�- r w , <br /> II.Type of Building(check all that apply) Lot a <br /> 111 10r2 Family Dwelling-Number of&cdrool'-• 3 1 Subdivision Name <br /> Block A ti4.. <br /> t: <br /> ❑Public/Commercial-Describe Usc - ❑City of • <br /> ❑State Owned•-Describe Use GSMNanber ❑Village-of <br /> f" U Ton f - <br /> • <br /> III.Type of Permit; (Check only one box on.)iue A. Complete litre B if applicable) <br /> A. <br /> New System ❑Replacement System ❑Treatme nUl loldingTank Replacement Only ❑Other Modification to L•nisling System(explain) <br /> 1.1. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Pemtit Transfer to New List Previous Permit Number and Date Issued <br /> Wore Expiration • Owner <br /> IV.Tyre ofPOVPI'SSyslan/Component/Device: (Check nli that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized lit•Ground g At-Grade 0 Mound>24 In.ofsuj(sble soil 0 Mound<24 In of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) " <br /> V.Dispersal/Treatment Area Information: - <br /> Deslgn Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Arco Proposed(si) System Elevation <br /> WS , C. _ 7S"'---_ .a o sit e.t S- 4,- <br /> VI.Tank Info Capacity In Total If of r Manufacturer - .g <br /> •Gallons Gallons UniLs <br /> New Tanks Existing e o $ A A^• <br /> c.0 in us • r+,0 'P. <br /> SCpricorllotdin1Tank /06.0 --- 00 c, <br /> Doting Chamber 65-a -.- ` rb / <br /> VII,Res onsibiliL Statement-I,tiro undersigned,assume responsibility for Iristaltallon tithe FOWLS shown on the attached plane, <br /> Plumber's Name(Prim) Plumber's-Signature MPrfvtl'RS Number Puniness Phone Number <br /> nftO l�etnk�1z. 1.A----e- ' , — 1 l�S X08 - `3 31- 143 <br /> Plumber's s Address(Street,City,Stale,Zip Code) <br /> VIII.County/Department Usc Only <br /> • ;Approved 0 Disapproved Permit FFcc Date Issued Issuing Agent Sl:• lure <br /> // �~ ❑Owner Given Reason for Denial s V 6y 7" �• r� • <br /> IX.Conditions of Approval/Rcasons for Disapproval 7��4� <br /> All WI is complete*T M.the splint and iubnlii la the County only On paptr roi lea than I I/1 I I I Inc es In Alta <br /> Dg_ Dil - • <br /> SDD-6398(R.01107)Valid thin 01/09 <br /> C elIK - 6041(14 - - • <br />