Laserfiche WebLink
Misvonsin <br /> .♦ ., "�.i. <br /> on.�)I I) - i., `-. - <br /> Department of Commerce 1o08)'ho i�i '7�G7J ll 3 <br /> Sanitary Permit Application State Plan LD.Number <br /> In acted with comm 8311,Wit.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(l sem) Project Address(if different than mailing address) <br /> L Application Information—Please Print All Information 3 e C> I <br /> Property Owner's Name /� _ O( Parod# Lot'#\Q Block# Z <br /> A V s F O)c3 / �- C, 2 0 d <br /> Property Owner's Mailing Address o Property Location <br /> 3 o.L Z I.teJ( Des /vQrtiee r Lwv,- <br /> City.Story Zip code Phone Number Y. _/. section <br /> 4 U!9�J t v" L S"l6 3(a t I (circle one) 16,X 4,6T 4D N; R/ <br /> II.Type of Building(check all that apply) J <br /> a1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name ' CSM Number <br /> ❑Public/Commercial-Describe use <br /> L„✓e i- (J00 d , <br /> ❑State Owned-Describe Use ❑City OVillage&ownship ofS-CJ�J, <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A- Whew System ❑ Replacement System ❑Treatment(Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. 0 Permit Renewal ❑ Permit Revision 13 Change of 0 Permit Transfer to New List Previous Permit Number and Date issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWT5 System: Check all that a 1 <br /> 'Non-Pressurized laGim nd ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter 13 <br /> Constructed wetland ❑Pressurized In-Ground 13 Holding Tank C3 Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching chamber 13 Drip Line 13 Gravel less Pipe ❑Other(explain) <br /> V.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Arra Required(sf) Dispersal Arra Proposed(st) System Elevation <br /> 3 as . 7 2 Sx,el - 970 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanta I Tanks <br /> Septic or Holding Tank ?J O <br /> Aerobic Tma[mem Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersign responsibility for Installation of the POWTS shown on the attached plans. <br /> Plum 's Name(Print) 's i MP/MPRS Number Business Phone Number <br /> -71 <br /> Plumber's Address(S City,State,Zip Code) 1 - 0 <br /> Gct <br /> ;-;L- -D6 e (,-- L.,4-lc <br /> VIII.Cour /De rtment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(inchdes Groundwater Date IssuedIsauiag ignature ) <br /> , .�SO <br /> C3 Owner Given Reason for Denial Surchatge Fee) 'r <br /> VL Conditions of Approval/Reasous for Disapproval <br /> 77 r 1 <br /> I' <br /> 2004 <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 c 11 inch"iYORN ETT COUNTY <br /> ZONING <br /> SBD-6398 (R. 01/03) <br />