Laserfiche WebLink
County / /' <br /> .01: 1,' Dane r (v.{ <br /> Safety and Buildings Division <br /> !ii -�' 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by C .)a <br /> :,,\S P 1:1 Madison,WI 53707 7162 <br /> S ( 3-2oi4— 0635'7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 5 11-..LEK13 1LL_ ROA p <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> t1/44.--A ,41 -I-E-i,u( P�pne_14i) _ tin I , (1 i\I l 1 or7 S ���3 -o39� -o <br /> in Address i ' __.__ ... ! Property Location <br /> Property Owner's Mailing -\ <br /> 3 Co 2 9 S48 evcro orh+ i R. I+I ;i Ci 2 2 2n14 Govt.Lot <br /> Zip Code ^ Phone Number 5141 '/a Section . O <br /> City,State p S 'A, S fu <br /> MO13OrJ W f p, tt,- 1; i T 7 N; R S E <br /> II.Type of Building(check all that apply) (_ Ft Lot# "h <br /> 1 � _ Subdivision Name <br /> 1I or 2 Family Dwelling—Number of Bedrooms 1 U/ '-6 I 1-CAA / <br /> ❑Public/Commercial—Describe Use Block# 5 riZACE., t <br /> ❑City of <br /> CSM Number ❑Village of <br /> ['State Owned—Describe Use [4 Town of IVI•L o P LE-ro- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ['Treatment/Holding Tank Replacement Only nOther Modification to Existing System(explain)EZi <br /> List Previous Permit Number and Date Issued <br /> B. El Permit Renewal El Permit Revision El Change of Plumber I(]Permit Transfer to New <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 ['Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑Holding Tank lather Dispersal Component(explain) <br /> ['Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> ds Dispersal Area Required(sf) l Dispersal Area Proposed(sf) System Elevation <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) P <br /> 6200 V 1 5-6 /—C 4-. 9245' '{�i ie) 4 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> o <br /> Gallons Gallons Units U <br /> New Tanks Existing Tanks J ,t,, w V & n in p., ( N. <br /> Septic or Holding Tank 1 At .(p j�.b�j o. t`A' -k"`V l- <br /> Dosing Chamber &5 o (ISO ( M`= el ( <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Name(Print) � 220165 608-831-8103 <br /> Andrew W Meinholz I -W <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VI .County/Department Use Only e <br /> Permit Fee G Date Issued I Issuing A <br /> Approved ❑Disapproved $ 1 <br /> 2/ / <br /> I <br /> 0 Owner Given Reason for Denial J 1 <br /> /0-)-14-11/ <br /> ' DC.Conditions of Approval/Reasons for Disapproval <br /> � Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> ' ^ <br /> ...... en nn m .7/1 t\ <br />