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County <br /> Safety and Buildings Division Dane l <br /> Si, ; 11 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S p Madison,WI 53707-7162 <br /> 3 3 CiObiC <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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),Stets. E gK eiz TrZA i L <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ,,--2-At • AKI D LyNt4 Pei-EA s 09II - I a,t- 0( 9 '7- 0 <br /> Property Owner's Mailing Address Property Location <br /> la f7 Si- A Lra E .T TH- Cj le.lc A--r t)g t v(G. Govt.Lot <br /> Ci ..,, Zip Code Phone Number ki In, 1..1r: 'Vs, Section 1.2— <br /> Un) Ple.11.I12.1 11J4 5 3 590 T 9 N; R f l E <br /> II.Type of Building(check all that apply) Lot II <br /> ig1 or 2 Family Dwelling-Number of Bedrooms 4 tom- S 7 Subdivision Name <br /> Block# D am ML l 1IJ CR <br /> D Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use <br /> N Town of GP.t5TOL <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System D Replacement System 0 Treatment/Holding Tank Replacement Only DOther Modification to Existing System(explain) <br /> B. ❑Chan List Previous Permit Number and Date Issued <br /> ❑Permit Renewal D Permit Revision Change of Plumber 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 OPressurized In-Ground at-Grade DMound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> DHolding Tank DOther Dispersal Component(explain) DPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> ds Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Pe 6 , 1 <br /> ,! oc, t,/' . (7 t//--S .) / Ci c19.0 • qci•0 <br /> VI.Tank info Capacity in Total #of Manufacturer 0 <br /> Gallons Gallons Units o ro' °- <br /> V H <br /> New Tanks Existing Tanks a o w .n a as <br /> A U u, 6/1 w 0 a.. <br /> Septic or Holding Tank I 1 p/ _ _ ja9)6 IAe(� <br /> Dosing Chamber 1150 (0 50 I I r.A V-Ao 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 — t'L, 220165 608-831-8103 <br /> I <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 Issui 1, Agen ` tl I W /' <br /> roved ❑Disapproved c'Ji-- -��' <br /> ❑Owner Given Reason for Denial /2 y�j /`— 1_ - a__- <br /> f Approval/Reasons for Disa royal /"� / <br /> 1X.Conditions o pp p U l ` <br /> 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 />