DCPZP-2008-00707 - Laserfiche WebLink

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tilt 2-- commerce.wi.gov Safety and Buildings Division County 201 W.Washington Ave.,P.O.Box 7162 Da Q. isco n s i n Madison.WI 53707-7162 Sanitary Permit/Number(to be filled in by Co.) Department of Commerce 'DB* ai•I L.6 el. ."P-14'7�\` ,_C-1 8'13 / Sanitary Permit A State Transaction Number In accordance with s.Comm.83.21(2),Wis.Adm.Code,submissio •• is f.i. t.I e 4roliria o eit ? TA,,,, g"' r ot ii� [ _ unit is required prior to obtaining a sanitary permit. Note: Ap I. . . s -state-ew � a.e4 1 Project Address(if different than mailing address) submitted to the Department of Commerce. Personal infornati. provide may be used for seco d. tt purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats.I P t yi 1 r ek.A e Q M C`b'e._ ""C ' I. Application Information-Please Print All Informatis M� 2008 € L, Property Owner's Name Parcel# �o� ,� �,,± ; \ © f� I 1 0601 0�3-ao8`1 -0 Pd�i;r }?alth tirOC Property Owner's Mailing Address Property Location Environmental Health vt s 5 9 'I f.) i-*_`C' 1 q,1•C e A.2 bf s S _ Govt.Lot City,State ( Zip Code Phone�Number N 1J1I ./, '�� '/, Section 1 ' a_Ai Slopt Li 1 5 3-3 1 -P-P ( 5 ^�(circl�ne) IL Type of Building(check all that apply) Lot# T N; R 1 lJr W b.1 or 2 Family Dwelling-Number of Bedrooms „5 9' Subdivision Name (� ` [ Block# tkIAt . 1 , �\ t 8 ❑Public/Commercial-Describe Use ❑City of ❑State Owned-Describe Use CSM Number ❑Village of ®Town of `•lirei,N�A J aa` 'Q IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) A. KNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existin g 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/Com_ponent/Device: (Check all that apply) ❑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.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(se Dispersal Area Proposed(sf) System Elevation -75O , (5, 150 '7 5 0 97. 0 • VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units „ 0 o $ New Tanks Existing Tanks v c y V L ro tt0 in " rn W 0 F Septic Melding Tank / c 0 /75 0 1 DA,`�v.-'ta-r be Dosing Chamber I V 0 0 j O©D / l 1 •it VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumb 's Signature MP/MPRS Number Business Phone Number Timothy J teN%-t..4-,.uteL6 227525 60R-845-7466 Plumber's Address(Street,City,State,Zip Code) 1 501 Commerce Parkway Verona Wi 53593 VIII.County/Department Use Only Approved ❑Disapproved Permit Fee Date Issued Issuing ent Si lure C /� ❑Owner Given Reason for Denial S 7e:�V 1 ' J oe �� l 7 wit/r . IX.Conditions of Approval/Reasons for Disapproval '----> SE: P-Q w . f /iAr4 A,e-A7' P�iv1 I.`, - :i; '1,DVyi_ D/NE -..'J TY Attach to complete plans for the system and submit to the County only on paper not less than 8 in'sit inches in size _ ..'S I N P f_A OR °SE.O i FI CA- - NS E AiMINAT O'.J C;:t./ER- NY I j,-, (FnT MAY SBD-398(R.01/07)Valid thru0l/09 ` r+ ivy-1A1..: " -� 4ND RESERVE..., ORDER CHANGES OR ADDITIONS Si 1UUJ .:W:GON l;-IONS ARISE MAKING THIS N,,E ,ARY.