Laserfiche WebLink
Jun. 22. 2009 11 :41Alk t'7 "_ — °-'Y-;i i� No. 0772 P. 1 <br /> ", ... i t I ''. <br /> cOmmer4 4.1. E9Ov Sttfetj+siijd Buildings Division County l' ''' J u N 1 a'l'}'W. aishi igton Ave.,P.O.Box 7162 `}(�N�, <br /> i � 1v)tiilisoh,WI 53707-7162 <br /> Sanitary Permit Number(to be Red in by Co.) <br /> Dspatynrent of rc@ 5C:2034249 <br /> iS�Anit�a.i:'`P' 'it A,: )1ieation state Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this tome to the appropriate govert.mental <br /> unit is required prior to obtaining a sanitary permit. Note: Application fonts for state-owned POWTS are Project Address(ifditlerent than mailing address) <br /> submitted to the Deferment of Commerce. Perumal information you provide may be used rm. secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name `, Parcel# <br /> '76('(\ '1 �Ebkiz6 j, t �.t�C�1 V C4{� ' \3-L':{ ctnioSill—)zl—_ '71.,5 -el <br /> Pmperty <br /> Owner's Mailing Address Property Location <br /> 5 c? (Ync H/ L t1 CDIN > <br /> Govt.Lot C^0 .- <br /> City,State Zip Crude Phone Number 4�.,E y,. e %, section /t_ <br /> tUi--i�.2 t..c)O lair „S3 caw- (circle one) <br /> II.Type of Building(check all that apply) lot 4 1' g N; tt_A_001-w <br /> I '1 or 2 Family lhvcllinv-Number of Bedrooms li to Q Subdivision Name <br /> --....---• lock# <br /> r7tN;'x�rar <br /> Block <br /> F Q.` w..k e C. <br /> ❑Puhlic/Commen ial—Describe[lse .,, S)---.....,. ^�?? t'lrs <br /> . .---..._....--_ ❑City of <br /> ❑Slate Owrted Describe Use CSM Number it Village of <br /> [..*-Town of Nt_.o. LP.,qzo.ji re_ _._-_ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> tANew System ❑ Replacement System U TreattienVlIolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. • fl Permit ttencrval i1 Permit Revision El Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration OMler t <br /> iV.Type of POWTS System/Component/Device: ((:heck all that apply) <br /> ❑Non•Pressutized In.Ground ❑Pressurized ln•Growtd U At-Grade 13d'Mound>24 in.of suitable soil U Mound<24 in.of suitable soil <br /> ❑ Holding Tunk ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) �,_ ......... .. , <br /> V.Dispersal/I'reatrnent Area Information: <br /> I)csign Flow(ppd) Design Soil Application Rate(gpdst) Dispersal Area Required(Sf) Dispersal Area Proposed(5f) System Elevation <br /> ts776 .. 43 0)(5 to s)._C) 7 7, <br /> VI.Tank Info Capacity in Total ii of Manufkcturer <br /> Gallons Ciallnns Units 2 1 <br /> Vew To,ks Iiristinx'f:'nks 8 O . e P r� <br /> Septic or l loltliag Tank ✓ I� 2- �C)'(o 1,4-'4"-i' e.t.�i c' ^`r <br /> Doe ugClusnlxr v� \I -fig ccliiJ? Pre_ ;z.hi. (.2.,.cst-;:i„ L- -� <br /> VII.Responsibility Statement- I,the undersigned,acsumc respuausihility for instattation ot the POWTS shown on the attached plans, <br /> Plumhcr's Name(Print) Plum 's Signature MP/MPRS Number Rosiness Phone Number <br /> l <br /> Plumber's Address(street,('.icy(itatc,Zip Code) , <br /> 41 1.4-5 6'. 9'0 ee_ •1 A !- 11R,) "T i^11Z1ca P 1 LO 1 C..3`i4 1 i <br /> VIII.Count /De artment Use fJnl - / <br /> `• Approved U Disapproved Perrmm(iitt�l Pet Data Issued 1r Issuing • enOgaa <br /> n(tuner(iivcn RGtson for l)cninl UV '�i 8 -j ,r,y.. <br /> IX.Conditions of Approval/Reasons for Disapproval r�- <br /> Attach to complete plans for the system and submit to the County only on paper not leas than 8 Irt=I I ins ittirc X <br />