Laserfiche WebLink
eir,.. . .. E C E O' V E —,P <br /> --), <br /> cortlmerce.wl.gov 1 n ty Min s Di 'ion County <br /> pp ane <br /> ., ,,,� S EYU 1�. u��r�►a.n Ave.,A F�13o1c 7162 <br /> t ns'n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> I-'uhhic N+r:-3! N 407-7 5 J B l y5 <br /> Sanitary p r' plichtitlih.-_I State Transaction Number <br /> In accordance with s.Comm.$3.21(2),Wis.Aden Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note•. Application form 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,a.15.04(IXm),Stats. CTH A <br /> I. Application Information—Please Print MI Information <br /> Prvperly Owner's Name Parcel# <br /> Steven&Christine Klann 0510-163-8135-0 <br /> Property Owner's Mailing Address Property Location <br /> 362 Bergamont Blvd. <br /> Govt Lot <br /> City,State Zip Code Phone Number NE v., SW %, section 16 <br /> Oregon,WI 75 843-6922 T 5 N, R 10(circle <br /> II.Type of Building(check all that app! Lot# <br /> GI or 2 Family Dwelling—Number of 3 1 Subdivision Name <br /> Block 4 <br /> ❑PublicACornmercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> 12052 LiTownof Rutland <br /> Ill.Type of Permit (Check only one box on line A. Complete line B If applicable) <br /> A. Iil New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑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 i Owner <br /> IV.Type of POWTS System/Component/Device•. (Check all that apply) <br /> ❑tNon-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.DispersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) l Dispersal Area Required(sr) I Dispersal Area Proposed(sf) ` System Elevation <br /> 450 0.5 1 900 Il 900 I 92.2'&94.2' <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Units ; 11 n <br /> New Tart Paining Tanks 2 y P .B a is <br /> o , yr w 3 w <br /> Septic or Holding Teak 1250 1250 1 Crest(700/550) x <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWYS shown on the attached plans. <br /> Plumber's Name(Print) 1 PI ben' Signature 11/C/MPRS Number mesa Phone Number <br /> fbkert L1 ei-SU}'l I ZiAl/ eeh, I , . .2/ it ( 8)63 -7i/ <br /> Plumber's Address(Street,City.State,Zip Code <br /> 5 0 2' L O'Ir i, 'p W( 533-'1 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued tss ent i <br /> ill <br /> ❑Owner Given Reason for Denial '52--° //i /D" `+�►-!I'0`? , IL 6 , <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system sad submit to the County only on paper not leas than!)to a 11 inches la she <br /> D6-a 7 ,28 CiK--- g41-16oG <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />