Laserfiche WebLink
‘,,‘• ."% County <br /> Safety and Buildings Division Dane r1/4A. <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ap • :: Madison,WI 53707-7162 <br /> ,?; ‘, S ;• <br /> 1 4) - /2 6 1'--.)— 0(-2.)(:.)(:)....-:...... <br /> Sanitary Permit Application State Tramaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the ap ropriate rverninental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state+eifii d POVT ',are Orc l. • j'rojqct Address(if different than mailing address) <br /> Is <br /> the Department of Safety and Professional Servies. Personal information you provi may qe-userIfor...se _DA, Ka , t i..;.-- <br /> purposes in accordance with the Privacy Law,s.I 5.04(1)(m),Stets. --te4j-Lc)r2,i . C out 12:1- <br /> . I. A*.lication Information—Please Print All Information r) ,, <br /> Property Owner's Name , 1 t M N — 6 2015 par'41): <br /> :RIFF 12\EA 6, PAT-12,t C 1 A cck L E.\c 44E._ fi-Lib&.- ?) ( 1 - 1-52o - <br /> Property Owner's Mailing Address . f .'.7 - ;,-- .,.-24iperty'Location <br /> 5554 712,EE LiNtE_ DR‘u E : F. <br /> ____.... h uovt.L.Ot <br /> -----...... <br /> City,State Zip Code Phone Number I\L -e v4, 1\tr 1/4, Section 3) <br /> NA.ta D i so 1..1 VU.1 ,....); /7 1 l T r7 N; R e) E <br /> II.Type of Building(check all that apply) Lot# <br /> [)D I or 2 Family Dwelling—Number of Bedrooms 4 2 0 Subdivision Name <br /> Block/I --- MALNAk sokt <br /> 0 Public/Commercial—Describe Use 0 City of . ............._... .. <br /> C3Statc Owned—Describe Use CSM Number 0 Village of <br /> NiTown oM i 0 L.X.,ei 0 11, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System 0 Replacement System 0 Treatment/ilolding Tank Replacement Only ['Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber riPermit 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 apply) <br /> NNon-Pressurized In-Ground 0Pressurized In-Ground 0At-Gratle 0Mound>24 in.of suitable soil ['Mound<24 in.of suitable soil <br /> 0 Hold ing Tank Either Dispersal Component(explain)_ 0Pretreatment Device(explain) _ _ <br /> ...._ <br /> V.DispersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil,Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> coo O. il ( s 00 isoo 8s-, s/ 8-7,6 <br /> VI.Tank Info Capacity in Total #of Manufacturer o ' <br /> Gallons Gallons Units t ic 0 <br /> New Tanks Existing Tanks '' '. z t.,' 2, <br /> _.._ <br /> Septic or Holding Tank 1.2.29C, <br /> Dosing Chamber tVriBe" ar9th 1"- ggig016LE / <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 .......A--c— e...A.) • ---).-- <br /> b 220165 608-831-8103 <br /> ,• <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> --- , <br /> VIII.County/Department Use Only / _ <br /> Permit Fee Date Issued Issuing Agent. ,..•-tire ior <br /> 0 Approved 0 Disapproved <br /> i / <br /> '`) ''' ''''.: ( 6 (5 <br /> 0 Owner Given Reason for Denial / ....,i _.. <br /> ._ <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 la s 11 inches in size <br /> , <br /> SBD-6398(R.11/11) <br />