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.'t pnnNfit County <br /> (Sy! , Safety and Buildings Division Dane <br /> D �" 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> t • �, C . Madison,WI 53707-7162 /3._ 20,ca3o6", 7 n_ <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 information you provide may be used for secondary <br /> in accordance with the Priv Law s.15.0 ,m,State <br /> I. Application Information-Please Print All Information NJ1r MI IN n1■ i l"VEIZ l3 ca, ROAD <br /> Property Owner's Name ' Parcel# <br /> MR,uC VU MAD i.so 4 t-LC MAR 27 206 or708- 263- 6243 -Q <br /> Property Owner's Mailing Address Property Property Location <br /> 6 a 01 S O1.�,1 ir1- TOW(V,E RIVE aC Govt Lot <br /> City,State Zip Code Phone 3 . %, sW '', Section ZO <br /> MA'D1.sCA1 WI • l3 T q N; R 8 E <br /> II.Type of Building(check all that app Lot# <br /> N1 or 2 Family Dwelling-Number of Bedroo 11 <br /> 3 Subdivision Name <br /> di <br /> Block# J mace. w <br /> ❑PubiicJCatnmercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> ' ®Town of M I I)1XF-1 01∎1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ®New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal 1=1 Permit Revision ID Change of Plumber ❑Permit Tinian.to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV. i,e of POWTS m/Com,•aent/Device: Check all that a• .1 <br /> MNon-PressurizedIn-Ground ❑Pressurized In-Ground 1At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank DOtiter 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(st) System Elevation <br /> r150 • y /875 /� S 9g??' �y'y� /9i9/976 <br /> VL Tank Info Capacity im Total #of Manufacturer <br /> Gallons Gallons Units I t°°° _ q <br /> New Tanks Existing Tanks g :A g A .� 0. <br /> t ^ 1! c�U v� en 6.t7 w <br /> Septic oelJoldmg Tank (�5° �� , U� -c <br /> Dosing C (iby ti <br /> r <br /> amber i pv ♦,t 1 r b \A <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of thheiPPOWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Melnholz 6i- .. 220165 608-831-8103 <br /> Plumbees Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> pp roved Permit Fee Date Issued lssuin. ' store <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> t� Attack to complete plans for the system and submit to the County only on paper not less than 8 U2111 inches in size <br /> SBD-6398(R.11/11) <br />