Laserfiche WebLink
Safety and Buildings Division Counry <br /> ` m m 201 W. Washington Ave.,P.O.Box 7162 Burnell <br /> Iseonsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 ��/ �(j <br /> Sanitary Permit Application state Plan 1.0.Number <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide /09 /.J5 7(o <br /> may be used for secondary purposes privacy Law,s 15.o4U)(m) <br /> Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All lnformatioo <br /> 7� Same <br /> Property Owner's Name <br /> Zion Lutheran Church Parcel# Lot# Block# <br /> 034-1528-01-200 <br /> Property Owner's Mailing Address <br /> Property Location Same <br /> 11841 Court Rd.Z <br /> City,State Zi Code NE'/h,NE'/., Section 28 <br /> Frederic WI P Phone Number <br /> 54837 (715)327-8384 (circle one) p <br /> Ii.Type of But <br /> (check all that apply) T 37 N; RI8 W cV�� lJl <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number N <br /> kPi blic/Commercial-Describe Use Church w/Kitchen 120 Patrons x 5 gal.=600 gal.x 5=3000 gal. Csm# J <br /> ❑State Owned-Describe Use <br /> Ocity_❑vivage•�fnwnanipoe TradeI,ake (y. <br /> III.Type of Permit: (CAeck only one box oa line A. Complete line B if applicable) <br /> A. ❑New System *Replacement <br /> R <br /> ePlacement System ❑ Treatment/Holding Tank Replacement Only EJ Other Modification to Existing System <br /> B• ❑ Permit Renewal EJ Permit Revision ❑ Chan a of List Previous Penni(Number and Date Issued <br /> Before Expiration g ❑Penni(Transfer to New <br /> Plumber Owe <br /> IV. of POWTS S em: Check all that Apply) <br /> ❑Non-Pressurized Jn-Ground ❑ Mound>24 in,of suitable$oil ❑ Mound<24 in,of suitable soil ❑ At-Orsde ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground X Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis sUTreatment Area Information: <br /> Design Flow III Design Soil Application Rm <br /> Est.Flow 600 gad NA e(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> NA NA NA <br /> Vi.Tank Info Capacity in Total Number Manufacturer <br /> Gallons Gallons of Units Prefab Site Steel Fiber Plastic <br /> New Existing Concrete Constructed Glass <br /> Tanks Tanks <br /> Septic or Holding rm k 3000 3000 1 <br /> Wieser Concrete Prod. x <br /> Aerobic TremaI Una <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown as the attached plana. <br /> Plumber's Name(print) PI 's Signal MP/MPRS Number <br /> Robert Carts Th Business Phone Number <br /> t�obev,e Son # 135655 (715)653-2500 <br /> Plumber's Address(Street,City,State,Trp Code <br /> 3 572 11511 Sheet Frederic WI 54837 <br /> 7C-ounrtment Use OnlDisapproved Sanitary Penni(Fee(includes Groundwater Date Issued Issuing giSurcharge Fee) qqrr Sn o Stamps) <br /> Owner Given Reason for Denial0,-511 pprovat/Reasons for Disapprovalo AStT� 5-~F mvn �erH ( a KA4 D06� r� �/la�os� of a-1Ysft{&O P6;X� /fpr.0n6 if)rUV- At4"AIII r�c6 AIAQO 56tWC4--'- A&6fAWSMdiJ-rS <br /> Attach complete Plans(to rhe County only)for the <br /> system <br /> oe paper ost las(tans#1R:Jl inches in size <br />