DCPZP-2008-00842 - Laserfiche WebLink

Home Browse Search

,_ r Z DI3.27354 Ch!4- 44333 . commerce_wi.gov Safety and Buildings Division County 201 W.Washington Ave.,P.O.Box 7162 0 0,4%.,G .Q iSC o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) Department of Commerce 5/ E I.A Sanitary Permit Application State Transaction Number In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental PA/4146- /bid/- unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing addre s) submitted to the Department of Commerce. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. E r I. Application Information-Please Print All Information Property Owner's Name Parcel# C19,ht" C r -r‘" 06,07 - .C.. , -(1106-0 Property Owner's Mailing Address Property Location Ll w l Q 4∎ -•E r N Cr' ' Govt Lot City,State t l Zip Code Phone Number g •tJ 1�1' y; ,b.I vi, Section N\kA i SUu `k, 1 531 ` ( ^3 7 6 t) (cire e ne) IL Type of Building(heck all that apply) T Lot# T N; R ____LE)r w g1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name Block# ❑Public/Commercial-Describe Use ❑City of ❑State Owned-Describe Use CSM Number ❑Village of it q6 1 g Town of 5.r`i►JG J AA\� - IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ®New System ❑Replacement System y ep y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV.Type of POWTS System/Comjionent/Device: (Check all that apply) ❑Non-Pressurized In-Ground ❑Pressurized In-Ground 14 At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.DispersaUTreatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation QO • 1000 ion C 100.08 VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units 2 o g, u New Tanks Existing Tanks v o 2 u s m o ft U vz cn w a-. Septic onimag Tank ,_300 130© 1 r)ak 4,- iy x Dosing Chamber '7 50 150 / 1 1 X i VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number Timothy J Jelle c .- 227525 4....c.�w�al, \ 60R-R45-7466 Plumber's Address(Street,City,State,Zip Code) 501 Commerce Parkway Verona Wi 535A3 VIII.County/Department Use Only Permit Fee o) Date Issued Issu A� Signature pproved ❑Owner Given Q--7 / %� ❑ Owner Given Reason for Denial S 7ey-� v G 8� �%%��f// C� [ I 1 X.Conditions of Approval/Reasons for Disapproval fK fq r� 't(z/7 r P` fJi-t1L. DANE.--. ****2;"*D c co e Maas for the system and submit to the County only on paper not less tlkdn B ii!i II inches ie s �.I t� ° � � � Val r p^ y lmt" L,( '� _o�v r.rT HOLD !Tu��i= T1Cr� �FcL.rbiNPi1�1 �F; SREDIFICA- ci` r L., C tv�ISSIONS �XA"nr D ' C)VER- S 398(R.01/071 Valid thru 01/ a S 11 CONSTRUCTION.' RESULTiidoR/..�-r tCETHATMAY AUG 2 2008 Trite RIGF I r� AND RESERVES ii SHOUt_L' %,L i i iC)NS ARTS `MAK NG THIS ADDITIONS L___.. P:ahlic Heath MDC NECESSARY. Emv,nnr_:e: _t-, 11_ ith