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oC,.A,.,u t' <br /> Countyr.. ,,.- <br /> • Safety and Buildings Division Dane � <br /> '''; 0 s Vi=i 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,�, P S Madison,WI 53707-7162 <br /> .:,. ,.::N%, (3 -z©t(1 - co3,ea <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. (L... ve-,SE Lc_ R©AC <br /> 1. Application Information—Please Print All Informatio <br /> Property Owner's Name <br /> M 12 -C, 0I4 MAD(scN (1,C 1le1d G1>,lt\IE�: S IN 61.4 Parcel gog - 20 -- co(11 - G <br /> Property Owner's Mailing Address Property Location <br /> (9 b°I SOL,1T1-1 T'O\h0 N1 E OR l U E Govt.Lot <br /> City,State Zi r od ' Phone Number <br /> Y∎ A 0l S cA\.( `d 3 (- ''/4, S Vil '/,, Section 2,0 <br /> II.Type of Building(check all that apply) } _IH II 1 Ler i� <br /> . T `7 N; R 5 E <br /> 511 or2 Family Dwelling—Number of Bedrooms ' :-- - .- '--; i j Subdiwi+sion Name I ' <br /> Block ft ` ' Sp2UCE '14OLLO(.J <br /> ❑Public/Commercial—Describe Use <br /> LW = ' <br /> • <br /> - 3 2014 0 City of <br /> ❑State Owned—Describe Use CSM Number El Village of <br /> Ott :!A., 0 Town of IN/Up 10'1-.17OIJ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. NI New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Chan a of Plumber List Previous Permit Number and Date Issued <br /> g ❑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 ❑Mound<24 in.of suitable soil <br /> Ell-folding Tank EiOther Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> �1 a0 . .l /6 '735' /43 7 o f�.-2 /o s�,'Sr�g�s: .z, <br /> VI.Tank Info Capacity in Total li of Manufacturer ; <br /> Gallons Gallons Units o v ^ <br /> New Tanks Existing Tanks vA c u y . rd <br /> r�U ht ti wc7 0. <br /> Septic or Holding Tank l Co 5 O 11950 ,-_:, 1 , ^ Q F .,/ <br /> Dosing Chamber CO Soo 1 y i�D X ` <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz .--� •^.'i.-'- (J 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> V .County/Department Use Only <br /> Approved ❑Disapproved Permit Fee D Date Issued Issui _ gen •: slur- <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ^'o 2. 5-7 Attach to complete plans for the system and submit to the County only on paper not less than 8 In z 11 inches in size <br /> SBD-6398(R. 11/11) <br />