|
r EV- 1�W1 E 7 i : YY, ,v
<br /> G[3IrltTteru- t Oov" S° e am� uildings Division County
<br /> . t 1 201W.W siin n Ave.,P.O.Box 7162 O 12 C
<br /> �" MAY 1 3 2009 Ma •ji,WI 63707-7162 Sanitary permit Numbererj(to�bbe fi�lle]d in by Ca)
<br /> Department o€a-., .i'ice - { ,57/ c–U /
<br /> {{ State Transaction Number
<br /> Sa ita , r �' r= a n
<br /> In accordance with s.Comm.83. 1(2),WniF jo sat ssi tlthis form to the appropriate governmental
<br /> unit is required prior to ob Y • g a sc ary permit : Application Corms 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),Stets.
<br /> I. Application Information–Please Print All Information K,.k /T– n
<br /> –500
<br /> Property Owner's Name Parcel it
<br /> Lave %n e_ °- g a s es /bin /1 4 c t r'e 6 5'0 F -- /7 2 807'0 -- /
<br /> Property Owner's Mailing Address ,/� Property Location
<br /> 5-11 f a- t-c -i/w ! Govt Lot
<br /> City,State J Zip Code Phone Number fi., E' y, AAA, �A, Section /7
<br /> G/o55 RI 6(1 )--S k� � �� 6 (circle one)
<br /> O N
<br /> EorW
<br /> II.Type of Building(check all that apply) Lot=
<br /> ilirl or2 Family Dwelling–Number of Bedrooms
<br /> 3 / Subdivision Name
<br /> Block':
<br /> ❑Public/Commercial–Describe Use ❑ City of
<br /> OM Number ❑Village of
<br /> ❑S tale Owned–Describe Use ,[" - �)
<br /> Town of 542t 1 y i
<br /> fr6vo7ea.
<br /> v
<br /> DI.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A- 4 New System ❑Replacement System ❑Trean nent/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain)
<br /> List Previous Permit Number and Date Issued
<br /> B. ❑Permit Renewal Q Permit Revision ❑ Change of PIumber ❑Permit Tranr to New
<br /> Transfer
<br /> Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> ■4 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-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(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation
<br /> V 510 i 7 6 -L 'G 7 , TS,o-- `t 7,0
<br /> VI.Tank Info , Capacity in Total #of Mannfarturer
<br /> Gallons Gallons Units a r) °
<br /> New Tanks - Eaishitg Tanks b o - ,. r `d
<br /> U v, w p 0 G
<br /> Septic or Holding Tars I /Dan I I MOO I t I e J I I I
<br /> Dosing Chamber I I I I
<br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
<br /> -Plumber's Name(Print) Plumber's Signature MPMIPRS Number Business Phone Number
<br /> leekI ''fh /11e/p" u2,~st.e. p ,2 / /`PK 6c $ ) VYY -V.77/
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 1 56 t Oar iin' Cofar T ° ete L.e.X 5-35-
<br /> VIII.County/Department Use Only
<br /> Permit Fee Date Issued Issuinc, ent Signature �e
<br /> ❑Approved ❑Disapproved $ ?�1� c_� _
<br /> ❑ Owner Given Reason for Denial ..77 6-- /1/45-;CD? `∎e /L
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> `r' ;;'Ci 1Hi At fj .?Vr, , DANE COUNT'
<br /> E F - {r gL� I'DOES i�OT HOLD I�SELF
<br /> T C.)N ;";, , S Id f'iA,JS OR SPEt,IFiCA
<br /> ''� 1�� _,�,ISIONS. EXAM1N,AT!ON OVER
<br /> ^, ;i�_= 7. C(liv( rRi i^TfON'':1r`� 1�Y U^o111/-1C-d T
<br /> j,\OQ: Atachta complete plans for thesystem and submit ta the Cauntyaalyoapaper not les�enCj,i.11;{nohe is e�R IN J,T� �YTiJi, iAC I�EE MA
<br /> D8- 1 O �1 45 ' - .5c ORDER Cl�gti'�:ES
<br /> Irl.
<br /> OR A HIS O•
<br /> M � Jw _; ;' i(.''�iTlr}^L'S ARlr ,J"q'<.It��(a THIS
<br /> -,.( SBD-6398(R.01/07)Valid-dun 01/09 ,fin \ _Cti,s Qi
<br />
|