DCPZP-2008-00938 - Laserfiche WebLink

Home Browse Search

12/24/2008 08:08 FAX 6088506848 Septic Specialists 1 J002 Ili . I it 4 Ii ! • D C 1 8 2D08 idings �- commerce_tvi. t)V� Safety an ! Division County m 44,1 201 W.Washington ve_,P.O.Box 7162 tiisconslin _l IIU 1-1..,-u l i,A sou.WI 3 707-7162 Sarrirary Permit Number(to be filled in by Co.) Department of Co c– EnviI nrr.t.I t _It)1 . 5 I S,2 o . State Transaction•Numbor Sanitary Permit Application • In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this forth to the appropriate governmental unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(if different then mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s. 15.0�1)(m),Slats. ! r dfe_pi (Z 1....Application Information-Please Print All Information — Parcel Property Owner's Name r:)j)"■.,2_IA i ig C._/ NZ C?i/- 30 3- 61 47 - o ' Property Owner's Mailing Address Property Location J i E.d e e_ Govt Lot _ Zip Code Phone Number 5j. y., S 6,' 'y., Section 3 0 ,City`, e ) q �(�CG�C, ne) II.Type of Building(check all that apply) Lote 7 Subdivision Name r2 Family Dwelling-Number of Bedrooms / u b / �r Brook IV iR 1 J r 0 1 f 7 4'�LF'-/V.) 0 Public/Commercial-Describe Use ❑ City of CSM Number ❑ Village of . ❑State Owned-Describe Use fg--Town of C `J2 i J/ l o / III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A' try System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) issued B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Before Expiration Owner J fV.7,' ■e of POWTS S :tern/Corn.onent/Devicc: Check all that a.. 1 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 in_of suitable soil ❑Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Displirreatment Area Information: Design flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation — VL Tank Info r Capacity in Total 0 o I Manufucturcr I Gallons Gallons Units r° 1 Now Teaks Fxisoay Tanis Cu U H t r.9 n ITT.5 W Septic or holding Teek a d„„c , ?��75,e) meet CII •Dosing Chamber nLr e p icz`e ; — ____L 1Vii.Responsibility Statement-I,the undersigned,assume responsibi for installs.on of the POWTS shown on the attached plane. Plums Name(Print) 1 Pltuttper's t ,� MP/MPR5 Number Business Phone Number C--�. 1` Gc R (f/os1).,.a .ff.& ' 11 c 710' ed , ) . ' 7 71 Plumber's Address(Street City,State,Zip Code) ? 3'Cr l 0ci ! C c!cs r i- Orue ELI 1-_ , q �%1 ._ .• County/Department Use Only Permit Fee Date Issued lss ..' ;' RIF /� Approved 0 Disapproved $ `� i�1 I��i Amp 0 Owner Given Reason for Denial IX.Conditions of Approval/Reasons for Disapproval �.E,C y '� /�,y13, , a�''v�l' �7� G lu PR��,/��n ,ra.=_ccul\IT1' '� c ('N �lr'1 i ! ENVIRONMENTAL HEr L'�Fl l-}QES'!OT i-OLP R);:':::_ry LIABLE FOR ANY DEFECTS IN PLANS OR SPEC IC/ TIONS,PLAN OMISSIONNS-,.,�tE�XAMINATION C\LF� Attach m complete plans for the nrytem and eub,nIr en the County on y on Paper not rem V IY VTS ANY DAMAGE M I"iA I IV9� RESULT IN OR AFTER INSTA!CATION AND RESE;=tv� ,\B.–3`7 f -,i 1 C40 K — 404.5--11- T 'E RIGHT TO ORDER CHANGES OR ADDI`u ONS SI?D-6398(R.01/07)Valid that 01/ 9 K SHOULD CONDITIONS ARISE MAKING THIS • NECESSARY.