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ti ,,ts,nru,', County <br /> Safety and Buildings Division Dane <br /> S • 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 /> . (3oorz . <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. 13A'1 LA U R E✓L LA k NI <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> MKE-C V174 MADIsoN LLC OniO8 - 243- Co144-0 <br /> Property Owner's Mailing Address Property Location <br /> 442 f)0 1 Sotti TCwN.e DRAVe Govt.Lot <br /> City,State I Zip Code Phone Number , t 2O <br /> M/�1'l$O 14 V.11 ,3°"71 3 S E /+, 51t(( /+, Section <br /> T 7 N; R 8 E <br /> II.Type of Building(check all that apply) i' Lot# <br /> ®]or2 Family Dwelling—Number of Bedrooms 5 1 0.4 Subdivision Name <br /> Block# SpFZU.L,E "1401-1.0\l� <br /> ['Public/Commercial—Describe Use <br /> ['City of <br /> ['State Owned—Describe Use CSM Number ❑Village of <br /> tI Town of I\ifirt.D0 l-,E—ro.i\l <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' NiNew System []Replacement System ❑Treatment/Holding Tank Replacement Only []Other Modification to Existing System(explain) <br /> El Permit Renewal []Permit Revision ['Change of Plumber ['Permit Previous Permit Number and Date Issued <br /> B. <br /> g L�1t'crmit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 121 Non-Pressurized In-Ground ['Pressurized In-Ground ['At-Grade Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ['Holding Tank ['Other Dispersal Component(explain) ElPretreatment Device(explain) <br /> V.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation/ / <br /> '150 6 y /8-7-C /$1'6 gle.9 9$.7 9$.S 983 <br /> VI.Tank Info Capacity in Total #of Manufacturer 8 <br /> Gallons Gallons Units iG t j3 <br /> New Tanks Existing Tanks A Cp B ti <br /> „A / a r3 rn a o7 iZ C7 E. <br /> Septic or Holding Tank 1 l0 50 1.5o 2. Iv - t O e <br /> Dosing Chamber Soo _ SOO I Me-APE X <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation o 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 .t__ L. ). ""y►--, 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only ' <br /> Permit Fee Date Issued Issuing Age ure <br /> ❑Disapproved j)(Approved ❑Owner Given Reason for Denial �` .At <br /> IX.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 tn:11 inches in size <br /> 6 e71 <br /> SBD-6398(R.11/11) <br />