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/ i 1 T1(F,y�,. -- County <br /> '�F� Safety and Buildings Division 004-e [ A <br /> Ds� t. } ' 201 W.Washington Ave., P.O.Box 7162 Sanitary Pennit Number(to be filled in by Co.) <br /> hi Madison,WI 53707-7162 A. <br /> ,.' < , l 3 — 2 cS—CXOLf <br /> "„ior,, <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 informal' y r d be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ED <br /> I. Application Information—Please Print MI Information 11`L.����.••rrr Oid n+'o vto;t x <br /> Property Owner's Name Parcel# <br /> (. 0,/,4 C 1'i p)-15 MAR -61015 0 etc14' -00,1 -- 1 too n0 <br /> Property 04ner's Mailing Address Public Health MDC Property Location <br /> 7 .5 r 3 am ro-uPii gd Environmental Health <br /> Govt.Lot <br /> City,State Zip Code Phone Number 514, ''A, Air ''A, Section ei <br /> Da e_ LU I- 5-3 5-A-5-A- q (circle one) <br /> n <br /> II.Type of Building(check all that apply) / Lot# T q N; R E or W <br /> ❑1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> 2Public/Commercial—Describe Use Sky W/ / C'rsp/vyet3 ❑ City of <br /> // <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> R.Town of Wennn* <br /> 1376y <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System El Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> g ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> ❑ 111 B• Permit Renewal ❑ Permit Revision Change of Plumber <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 /> ❑ Holding Tank ❑Other 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(sf) System Elevation <br /> I `l // Sir- a 7 O q 5+,,- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a) o 2 <br /> New Tanks Existing Tanks - o Y " 5 i <br /> aU c, w0 0, <br /> Septic or Holding Tank 6 c.., 3 UU <br /> / . /J"/edge d <br /> Dosing Chamber <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 <br /> KENNETH MEIER x 224144 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> 111 Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <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 1/2 5 11 inches in size <br /> SBD-6398(R. 11/11) <br />