Laserfiche WebLink
(2Jieck Tr) 38 .2 ! 131-1) . 7 5' <br /> ..; 7,1? . -�',`afety •?nr ildings Division County <br /> 201 W.W. ingt. Ave.,P.O.Box 7162 ,eJJv/' <br /> - '• a UbIiC Health MD: ,t n, I 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> flviron ental Health 5 ( 7 9 2. 3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Application forms 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 /> .0 .. es in accordance with the Priva Law,s.15.04 1,m,Stets. <br /> I. Application Information—Please Print II Information t-tIE12A L d 7 'i2 4e'/p <br /> Pro Owner's Name Parcel# <br /> y ti' t lc G� � pdJ C5C/( 9 e 7 (Z(-e159t- <br /> Property fOwner's Mailing Address q '/ Property Location <br /> V-- 'I 6' e0 Ai,U JA C 191t,1(I 1�t ti Govt.Lot <br /> City State <br /> , Zip Code Phone Number�^, Ale-. V., 6,e y,, Section . <br /> ri,DPLe 1 �j l�l `�L3St iF O� ( /�S - 7,i--5 T q N; R irc/ eW <br /> II.Type of Building(check all that apply) t! Lot# <br /> lr 2 Family Dwelling-Number of Bedrooms eJ& Subdivision Name <br /> Block# f`:ST,' 1 !-/gi e e5%ATes <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use I <br /> Town of C))Ck)u f y <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. n •ew 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 Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply)_,,, <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis s ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil A plicat n Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> /.:304L 1.0te %c r .0> /1/7(1 4,jr 95.95 <br /> VI.Tank Info Capacity in To #of Manufactjsfer <br /> Gallons ons Units v d° <br /> m v <br /> New Tanks Existing Tanks t c Z al I n R <br /> B a. 6 w rn to P. <br /> Septic or Holding Tank j ♦ %2,, / 6O / ftj e•SQs� 4 <br /> Dosing Chamber / U(n Ccez' , t _ L <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWYS shown on the attached plans. <br /> Plu is Name(Pr t) Plumber's Si nature MP/MPRS Number Business Phone Number <br /> 17mek r le /kel in' ) k1 ike 'Y . ?)Y-7,7`7 -CY—IV:1-zgii/ <br /> Plumbers Address(Street,City,State, i Code) V <br /> ``q . .Si /In/2/e cL' 5 ig c , cj, 6:35 7? <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent . cure <br /> Approved ❑ Disapproved �� <br /> ❑Owner Given Reason for Denial $ -18,— /) 08 yvvY <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1R x 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />