Laserfiche WebLink
l', 119 1', 11 1'/ C-= 1 _I <br /> MAR 4 2009 <br /> _ i <br /> commerc wl.gov Safety and Buildings Division County <br /> • = 201 WrWashington Ave.,P.O.Box 7162 �G�V.tt� <br /> 'S CO t�_�! _!l a{1tsQa. t 53707-7162 Sanitary PermitNumbcr(to be filled in by Co.) p <br /> Department of Commerce 5/ Q c/�Q . <br /> Sanitary Permit Application Statc Transaction Numbcr <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 arc 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. ✓4_ /� <br /> I. Application Information-Please Print All Information 'J �C <br /> Property Owncr's Namc Parcel if <br /> -e_ SC.L 0e/le ,'v7 el vi 0c:.`7- 3y/- $UO3- <br /> Property Owneri Mailing Address Property Location <br /> �L.. <br /> / e u g -L . S Si -" <br /> City,State Govt.Lot <br /> Pk-, Zip Code Phone Number • ,' E y, /v y., Section 3y <br /> Vy°Ss P/ -,'.'S cI ;. S 35:1 v ,S)G.- S/HE. 7 0 (circle one) . • <br /> II.Type of Building(check all that apply) Lot it <br /> T a N; R 7 EorW <br /> XI or 2 Family Dwelling-Number of Bedrooms / Subdivision Namc • <br /> . Block if <br /> ❑Public/Commcrcial-Describe Use ❑City of <br /> ❑State Owned-Describe Usc CSM Number ❑Village of <br /> 9 8 37> gTown of Pe-fr-2 <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) • <br /> A. )'New System y 0 Replacement System ❑Trcatment/Holding Tank Replacement Only 0 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 /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade Mound>24 in.ofsuitablc soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Dcvicc(explain) <br /> V.Dispersal/treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(s0 System Elevation <br /> VI.Tank Info Capacity in Total if of Manufacturer <br /> Gallons Gallons Units c v u <br /> New Tanks Existing Tanks W c u Ti 1 n <br /> . : o t <br /> a:t.) 'en to m wa 'i. <br /> Septic or{folding Tank ! O 6 o /Z6 a / ✓‘/e k.' <br /> Dosing Chamber 4-5-. t S / ti, x <br /> VII.Responsibility Stateent-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Namc(Print) Plumber's Signature hM.WMPRS Number Business Phone Number <br /> w- Pei.,tottz L). a. 7.)/6 •r 60 El- 83/-81o3 <br /> Plumber's Address(Street,City,State,Zip Codc) <br /> 6 8/3 cm "k Ai. / Lie lam, t.J. . x rr -7 <br /> VIII.County/Department Use Only <br /> fiApprovcd ❑ Disapproved Permit Fcc Date ssucd Issuing Age. ••nature • <br /> Q .�— i�1 <br /> ❑Owner Given Reason for Denial $ F09, - 3/ 6/D9 / • <br /> IX.Conditions of Approval/Reasons for Disapproval ■ <br /> IN GRANTING THIS APPROVAL, DANE COUNTY • <br /> ENVIRONMENTAL HEALTH DOES NOT Iartp I Li <br /> INVI <br /> Attach to complete plans for the system and submit l the County only on P4:1 <br /> 0 le 'id x Fiit i Il&INBI PLANS OR SPEC <br /> IFICA <br /> 06 - <br /> a �5 �' SIGHT, CONSTRUCTION OR ANY DAMAGE THA- <br /> RESULT IN OR AFTER INSTALLATION AND RESERVE <br /> SBD-6398(R.01/07)Valid thru 0009 THE RIGHT TO ORDER CHANGES OR ADDITIONS <br /> �l l^ r— L� "7 2Q 2 SHOULD CONDITIONS ARISE MAKING THIS S <br /> W Y / IJ NECESSARY, <br /> • <br />