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County
<br /> ...f Safety and Buildings Division Dane
<br /> OS : ::.;t-,, , ,--:. 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Num in ber(to bc filled by Co.)
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<br /> Madison,WI 53707-7162
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<br /> 1 3-2015- Od5--`-7
<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 rovide ma be used for secondary
<br /> pommies in accordance with the Privacy Law,s.15.04(1)(m),,Slats. '
<br /> L Application Information-Please Print AII Information E EIVED vE LA< ROA D
<br /> Property Owner's Name Pared#
<br /> TY L.,F--R- 'CI,1■11) KA•iLA SA IN.ui5oRi\i MAR 2 0 205 00 c(- 12.3 -4riti -0-
<br /> Property Owner's Mailing Address Property Location
<br /> I I ( 5 W. IAA 0
<br /> (64 „..7-rx.E.E,-t- Public Health MC
<br /> Environmental Health Govt Lot
<br /> City,State Zip Code Phone Number 5Aid 1/4, S Lii 1/4,SectiOn 1 2.
<br /> Sutt./ .PkAtRiE Wt 530,0
<br /> T 5 N; R flit
<br /> IL Type of Building(check all that apply) Lot#
<br /> a or 2 Family Dwelling-Number of Bedrooms 1 9 Subdivision Name
<br /> Block# SAVA-KIM A 14, \-/A Lt-E`f
<br /> OPublic/Comtnereial-Describe Use
<br /> 0 City of
<br /> CSM Number 0 Village of
<br /> OState Owned-Describe Use
<br /> IKI Town of )U is4 Pfe..4 I_RA
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. 1 IX New System Di Replacement System I:Treatment/Bolding Tank Replacement Only []Other Modification to Existing System(explain)
<br /> . Previous vious Permit Number and Date Issued
<br /> B. El Permit Renewal 0 Permit Revision ['Change of Plumber filPermn Transfer to New
<br /> Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> ONon-Pressurized In-Ground OPressurized In-Ground DAt-Grade []Mound>24 M.of suitable soil ( Mound<24 in.of suitable soil
<br /> 0 Holding Tank DOther Dispersal Component(explain) DPretreatment Device(explain) _ . _
<br /> V.Dispersal/Treatment Area Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required Of) Disper"1-Area Proposed(sf) System Elevation
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<br /> VI.Tank Info Capacity in Total #of Manufacturer B t.,:,
<br /> Gallons Gallons Units _
<br /> New Tanks Existing Tanks ''g t-
<br /> 0,0 c75 cn as u.t., 5-
<br /> Septic or Holding Tank LL a(., i.v.?_A, -2. ILA:FADE X
<br /> Dosing Chambet Ce 0 115-4 J I ktr.ADF x 1
<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-4— L'-' - ---)---6 220165 608-831-8103
<br /> Plumber's Address(Street,City,Slate,Zip Code)
<br /> 6813 County Highway K,Waunakee WI 53597
<br /> VIII County/Department Use Only ,
<br /> P it Fee 0 v Date Issued , •s isg , .,-,,,,,rri• ,,,,„7"
<br /> ?c121.4zproved D Disapproved i
<br /> , 0 Owner Given Reason for Denial $ zi-t60,--- 3/2.314..sj __... ,
<br /> IX.Conditions of Approval/Reasons for Disapproval , .....-2-,:-.----
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<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8112 a 11 inches in size
<br /> SBD-6398(k 11/11)
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