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06/23/2008 15:28 FAX 6088506848 Septic Specialists 81002 <br /> • <br /> -Da *AL•ki - c k.ft el <br /> eommerce.wi.gov Safety and Buildings Division County ) <br /> 201 W.Washington Ave.,P.O.Box 7162 c(.t e. <br /> tfisconsin Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce ...... 5/80Q 9 <br /> Sanitary Permit Application STransaet;onNtunber 9 <br /> In accordance with s.Comm 83.21(2),Wis.Adm.Coda,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitay permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the DepartMem of Commerce. Personal information you provide may be used far secondary <br /> purposes in accordance with the Privacy Law,s.15.04(i)0p),Stats. <br /> L A..lication Information—Please Print All Information '/c.°j .4e <br /> Pro Owner's Name Parcel# <br /> .,1 I.kh " r c .� , o O - Q�oa . Q io 0 <br /> Property Owner's Mailing Address Property Location <br /> - 3 ``a r & C4 (c_ Pm <br /> Govt Lot <br /> Crete Zip Code Phone Number �� �J Y. A/4}/. Section vZ O <br /> CA nt-e -4CJ� S-3 S 2 Y o ,; ale one) <br /> II.Type of Building(check all that apply) Lot T 0 N, R v <br /> OE 1 or Family Dwelling—Number of Bedrooms a Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> III.Type of Permit: (Check only one box on line A. Complete lineB if applicable) <br /> A <br /> Nee System ❑Replacement System ❑Treatment/Balding Tank Replacement Only ❑Other Modif cation to 1 isstina System(explain) <br /> B. ❑Permit Renewal I ❑Permit Revision ❑Change ofPJumber ' List Previous Permit Number and Date Issued <br /> ge I ❑Permii Transfer to New <br /> Before Expiration I.Owner <br /> I.!.I'Ype of POWTS System/Component/Device: (Check all that apply) <br /> on-pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound?24 in_of suitable soil ❑Mound<24 is of suitable soil <br /> ❑Bnldine Tank ❑Other Dispersal Component(explain) ❑PrstraettneniDevice(explain) <br /> V,Dispersal/Treatment Area Information: <br /> Design Plow(gpd) Design Sal]Application Rate(gpde) Dispersal Area Rnqurtd(sf) Dispersal Arse Proposed(sf) System blevetion <br /> VL� (fi r `� //0>J 11 jy 7,?,19 �,J�� /oo a ' <br /> VI.Tank info Capacity in Total iR of Manufacturer <br /> Gallons Gallons Units c <br /> New T®ks I Existing Tanks - d " <br /> cu c, ie. Q A. <br /> � — <br /> Sa sic or 14olding T®lc /V nC I 4 QG 1 frPFIJJ 1' Ce <br /> boring Cb tuber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the studied plans. <br /> Plumber's Name(Print) ' Plumbg=SigratUP. 1v1PflORS Number Business Phone Number <br /> Plumber's Address(Street`MiTie.,Zip Code) �� <br /> 73c ,r -pgi- 1 ; e f, ^bANc Lamy s-j s <br /> VIII.County/Department use Only <br /> '7r-Approved Disapproved Permit Fee Date Issued ]scum= t Signature <br /> ❑ Signature <br /> ❑ Owner Given Reason for Daniel <br /> S` Q' 0� 4-zn_�_ C i <br /> I X.Conditions of Approval/Reasons for Disapproval <br /> IN GRANTING TEAS APPROVAr. DANE i:pU>`J)'Y <br /> ENVJFIOIVMENTAJ_HEALTH DOGS NOT HOLD JTSJrLF <br /> UABL FOR ANY DEFECTS IN PLANS OR SPECIFICA <br /> TIONS, PLAN OMISSIONS <br /> SIGHT CO■ r _ N�+1?ON O`lg. <br /> Atmch m complete pleas for thery5eees and Submit to the County only ou yip 7F' - 1/41911161311:..i' R INSTALLATION AND T S RV E' <br /> SHOULD CON ONS <br /> ARISE MAKING THIS DONS <br /> sea 5 98(P:01/07)Valid tbrtr 01/09 NECESSARY <br />