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County
<br /> ,.: Safety and Buildings Division Dane iv■6-
<br /> .s .i."':g• . f: 201 W.Washington Ave.,P.O.Box 7162 Sanitary,Permit Number(to be filled in by Co.)
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<br /> Madison,WI 53707-7162
<br /> .„: s .:
<br /> i —20 cl 00 q-36.
<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 mail-.,.address)
<br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
<br /> _ 1- CILE.12, Li c...,/ Co u RI"
<br /> purposes in accordance with the Privacy Law,s.15.040)(m),Stars.
<br /> L Application Information-Please Print All Information
<br /> Property Owner's Name
<br /> VE_Rt,o1.4N) 1--tom.eS STI3 1-1...C ; ''.7-. oezog-2_03- ZZ1 2-0
<br /> Property Owner's Mailing Address -,,
<br /> Property Location
<br /> 6 bol S0.4_4„-n+-1- VV 14 E DR.%v 0 3= !„, f ' . Govt.Lot
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<br /> City,State Zip Cori , Phone Number
<br /> 6.- NIA/ 'A,51,4 v.,Section 2-0
<br /> NAADL501.) . WI --- ,-5•3'7 1,3 r - ' 1
<br /> i . ' — T 1 14; R. 0 E
<br /> IL Type of Building(check all that appl)() . ' frnt 8
<br /> gi or 2 Family Dwelling-Number of Bedrooms ," 'Ca. ________
<br /> Subdivision Name
<br /> Block 8 5
<br /> ['Public/Commercial-Describe Use
<br /> 0 City of
<br /> Village of
<br /> ['State Owned-Describe Use CSM Number El
<br /> Lg Town of Mtor)(....e..-r-zyk1
<br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable)
<br /> A 2 New System El Replacement System NiTreatment/Himmeesfil Replacement Only []Other Modification to Existing System(explain)
<br /> TANKS ONLY
<br /> B. CI Permit Renewal 0 Permit Revision ID Change of Plumber DPermit Transfer to New List Previous Permit Number and Date Issued
<br /> Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that appl
<br /> DNon-Pressurized In-Ground OPressuriz'ed In-Ground Dm-Grade Mound>24 in.of suitable soil DMound<24 in.of suitable soil
<br /> ElHolding Tank lather Dispersal Component(explain) DPretreaunent Device(explain)
<br /> V.Dispersal/Treatment Area Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Pr (sf) System Elevation,_
<br /> r150 alf.‘ —7 5,-) (t 2,s, -75-1, frs-6,
<br /> VL Tank Info Cap ..in Total it of Manufacturer
<br /> o
<br /> Gallons Gallons Units
<br /> 1 ts Q rt T, l El TS
<br /> New Tanks Existing Tanis
<br /> '- L;?.ri iii r 4-'
<br /> 2
<br /> i nq g
<br /> Septic or-fielding Tank 1,te 50 ....- u.50 A- Mg.A o q X
<br /> Dosing Chamber
<br /> I Soo ..__
<br /> 500 ,i
<br /> VII.Responsibility Statement-I,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 _./4---"C- 4i)- -1------- 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 IssuinigZSp
<br /> Je4pproved 0 Disapproved ..-, al.."-
<br /> 0 Owner Given Reason for Denial
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> rtptc#7,,v4 41- fr-. 7-- P-44/PY-.146-
<br /> 19/61Z.-1. "gt4^60 Cr l'r /t,
<br /> .rOfe.-. coyor..-raer X9rc_ gicA14.4"T4nre4-...c.P 1€14taie-,4yr-rit.trsc,
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<br /> 613-20 2_ Attach to complete pleas for the system and submit to the County only on paper not less than S t/2 x it inches in size
<br /> SBD-6398(R.11111)
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