Laserfiche WebLink
County <br /> ;a. Safety and Buildings Division a- . Y- Re) <br /> t.' , <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> � `� ;T <br /> $ 1=i Madison,WI 53707-7162•PS I:i t' .-' 0\S ''C CU 1 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the .ropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms ,a ,,r.e. - u", to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal infarmatio l'• rs 1 b •, .r s ary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stets. <br /> I. Application Information—Please Print All Information MAR 2 6 2015 Parcel# <br /> Property Owner's Name <br /> /q//e4..1 f /4/4,-se7 1./e-rVvd / 1 <br /> Public Health MDC 6767— c2./2 Sri° — 0 <br /> Environmental Health Property Location <br /> Property Owner's Mailing Address <br /> 76 a 4 6,2c/fon Oi, VC— Govt.Lot <br /> City,State Zip C..a Phone Number /l,/&i y,, N�1 '/,, Section <br /> -MA oLiSo7 , 6n3 ; S 37/ T 7 N; R 7 E <br /> H.Type of Building(check all that appl ) Lot# / <br /> Subdivision Name <br /> l or 2 Family Dwelling—Number of B ■ ..Y <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> CSM Number El Village of <br /> El State Owned—Describe Use <br /> /(2-7 8 5" Flown of Gr.u S$ p lo./it S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. gNew System ❑Replacement System ❑Treannent/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal CI Permit Revision ❑Change of Plumber O'ermit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ['Pressurized In-Ground ,ElAt-Grade :Wound>_24 in.of suitable soil ['Mound<24 in.of suitable soil <br /> 0 Holding Tank ❑Other Dispersal Component(explain) <br /> ['Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Dispersal Area Proposed s System Elevation <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) l Dispersal Area Required(sf) p rs lA o o (0 l Se f s7 f{' <br /> � bv <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units A 5 ° <br /> New Tanks Existing Tanks XI r 1 i rn i£O P. <br /> Septic or He1aier nk /2-s G /e)-8 6 a . e,,,4- <br /> Dosing Chamber 6,So ._. l,Yo I U <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Signature I MP/MPRS Number Business Phone Number <br /> Plumber's Name(Print) 220165 608-831 5103 <br /> Andrew W Meinholz -- LA), 1 <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 Pee Date Issued Issuing ant 9' star <br /> )(Approved ❑Disapproved $ •3 27 20/cl e 'Al-e'l4Ar--- <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovaUReasons for Disapproval /3-- i<7. .P40144/1/JLJ,e- / //7V Be--- '''e` 7 c..7� <br /> f —Gtf-adct f rrt2 a <br /> FRo/1 foie_ C4 * I I c'to E7'-c-41'E7'-c-41'4-71''"'t � l JtG"` T <br /> c <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 inches in site <br /> SBD-6398(R.11/11) <br />