Laserfiche WebLink
• <br /> '- <br /> cammerce-voLgov Safety and Buildings Division Ley <br /> 201 W.Washington Ave.,P.O_Box 7162 DANE - <br /> ■SCOf Madison,WI 53707-7162 Sanivev P+amit Fresher(to be tiled.by Co-1 <br /> ,Si 'oiI of Cammonse Stets Trasactioa Number <br /> Sanitary Permit Application <br /> In accordance with s.Comm.83.21(2),Wis.Mm-Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary pert- Note: Application forms for state-owned POD tife 'pry Add, (if duos dim'soTiute address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 3884 OAR PARK RD <br /> ,. .. -'in accordance with the • Law.s.15.0 1 in,Slats. <br /> I. Application Information-Please Print All Information _ - °-- <br /> • oimer.s Name Parcel#024-0712-202-9665-6 <br /> REX PORTER - horny <br /> N ewly Owner's e�.*. <br /> Addr Location <br /> 102 W NORTH LAWN DR ,,,L Lot 1 <br /> City.State Zip Code Phone timber SE v,NW'4. Section 20 <br /> COTTAGE GROVE WI 53527 608-577-5660 (circle one) <br /> t7TT: R12Wl <br /> H.Type of Building(check all that apply) Lot it - <br /> 1 or 2 Family Dwelling-Number of Bedrooms 4 Subdivision Name <br /> Block a <br /> Public/Commercial-Describe Use City of <br /> UState Owned-Describe Use GSM Humber ❑Village of <br /> Q 8 2 2. Town of DFERFIELD <br /> Dl. of Permit ( • only one lam on line A. Complete Ike$if able) <br /> X01 a Replacement U Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> System <br /> Illill ; it LJ Permit Revision -0 Change of ❑Permit Transfer to List Previous Pamit Number sad Dale lbsacd <br /> Renewal 13eferc Plumber New Owner <br /> Expiration <br /> IV.Type of POWTS Sy SyaleatKompenestiDevice ,�ii tart <br /> ®Non-Pressurized 1n-Ground ❑Pressurized In-Ground At-Oracle Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ©Pretroannent Device(explain) <br /> V. Irr'r'entlMent Am I.finnatti is <br /> Design Row(gpd) Decip Soil Application Rale(gp bU Dispersal Area Repaired(et} Dispersal Area Propped(st) System Elevation <br /> 600 0,N 1500 1500 ql•5 -- q'l-s <br /> ,r <br /> VL Tank Info Capacity is Total 4 of Maraabcipow E <br /> Gallons Gallons Units 61 <br /> � �, pU� a � � °1 <br /> New Tastes E�iN. Tada a o L �' !n 1 <br /> Tare 1250 — 1250 1 DALMARY CONCRETE /_ .meiHI. U <br /> 1 750 750 1 DALMARYCONCRETE ►,t • * I� <br /> VII.Respaseitartty Sweat-I.the naderaigaed,ammme responsibility for installation oldie.POWTS shown on the attached plans. <br /> plomber's 7 MPRS Number Tuskless Phone N <br /> mdmr <br /> JAMES Name(Print) 139411 920-568-0524 <br /> Pl.rher'x Address(Street.City.Slate Zip C <br /> / <br /> W36 Hebron.RD,FtAtkinson WI 53538 _ f <br /> VI ,a partmen t Use on. ly._ - ,-- <br /> _ Dist coved Pnnit Fee I)arre .-., ,, - <br /> ' _Owner Givca Reason fur Denial S,33 f r~► , _. <br /> j� <br /> -�+�( ,_ b I �I �• t <br /> 'ire ,bons of Approval/Reasons for Disapproval el1.111", . .\stit. <br /> E C EM_,—1-) i°15* 4--.6°114°%4F—t-cl —d‘l 9: <br /> li, ors far ere spans anal asbmrr w vie eo a+y 1st/as raps-st rm Ism C v2 s II+eta r vier <br /> JUN 5 2008 <br /> Public Health MDC <br /> Environfl1errtal Health.. <br />