Laserfiche WebLink
• <br /> i <br /> A r r I \I as EN <br /> commerce. IP�lpLi�s���s�• t i'lli dines Division County <br /> 201 W.W: • 7 P, Ave.,P.O.Box 7162 e <br /> isCOfl - 7 �� • l 53707-7162 Sanitary Permit Number(to be filled to by Co.)Department Of . ;_ J L 2 4 200: /�' u a1419 5/S 087 _ <br /> Sans r 1 ���•I,�ku ^ State Transaction Number <br /> ( ' ' ," ' C ppro governmental <br /> DELL Pc�' (s l Cf13 614 <br /> In accordance with s.Comm.83.21 2 Wis. • if form to>11e <br /> unit is required '• .11"til lyn.�7.141 - - <br /> equir prior to obtaining a - .. .�. ... .., 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 cwt r2 aD e ,147- 'w . <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 3(2��T 2 E t --E L /,.)/A. <br /> Property Owner's Mailing Address Property Location <br /> C1,.> l4r,w h-RJ) Z,wEt_.� .(.,J lit°l ca.t r2. 1(21:), <br /> City,,State <br /> QY Zip Code Phone Number S w 'h, SF__ 1/4, Section .."41 <br /> UHF—(2-17 0 A ) w i J 3s-e? ( c9 8`FS- 7 F63 <br /> IL Type of Building(check all that apply) Lot# T N; R E <br /> �2 Family Dwelling Li I Subdivision Name <br /> y elling-Number of Bedrooms <br /> Block y <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of _ <br /> ( Z�{ S9 ®Town of Ue20,`rA <br /> IIL Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A �t'New System yst El Replacement System ❑Trealatent/Holding Tank Replacement Only 0 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 Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 is 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(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevation <br /> 6 07 ,'c. l60o / oos ! oR-7'1 tl(. J (l?__ 6 <br /> VI Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks F•i,nn?Tarilrs w C <br /> .2 i o 1 m <br /> et., C.) "va m t.15 <br /> w0 G <br /> Septic eriSetektg rank /6 _ <br /> .----- /r. e / 9I L`/V� ft-4"Z P��' X <br /> Dosing Chamber <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 iti.P/MPRS Number Business Phone Number <br /> TI VA 0i1-1 Y 3 E t_L _ "NNl `J rc 22-7 S 2 S (L 00 8 Les--7t/G <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VElmr•JA 5aPT1 c Sir £XCAvATI/JG1 5° C.ovvl,,vlE.Re-I Pv_tr...,`-r) tJE./2-0"Jf2 , t t.J1 ,. • 3.5 3 <br /> VIII Countv/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent i e <br /> ov <br /> ❑Owner Given Reason for Denial S 3 v-7 r7-2 Y-O ✓K'� 4 i <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> P- . .G,- -- --J,, i 1 virvx--(--tzfr----\--in(-7 , ( <br /> Aitacb to complete plans for the system and submit to the County only on paper not less than 8 1/2 z 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />