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_?,:t'''-'''ti: County <br /> Safety and Buildings Division Dane <br /> 2 D 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filed m by Co.) <br /> `--S P 3 ' Madison,WI 53707-7162 <br /> - 132.o1s-urns to <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(lxm),State. - SaI�M VALLEY CIRC LE <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> LON ALBRec4r 0810 -044- 9 Sao-p <br /> Property Owner's Mailing Address Property Location <br /> 94:2 k;rl bar/van & t- Govt_Lot <br /> City,State Zip Code Phone Number 56 r�� r /r <br /> e�U14PI2,AiRIE \#J1 35'" d p N; R /t Section `? <br /> IL Type of Building(check all that apply) Lot# T O N; R E 0 E <br /> EC l or 2 Family Dwelling-Nwnb f_. ,r.. 1 4 it• .� I Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use <br /> APR 131015 ❑city of <br /> ❑State Owned-Describe Use CSM Number 1=I Village of <br /> Public Health MDC <br /> Environmental Health 1'33(07 ®Town of $fkft..ICdE <br /> Ill.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A_ MNew System ❑Replacement System ['Treatment/Holding Tank <br /> Replacement Only ❑Omer Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision ❑Change of Plumber it Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> XNon-Pressurized In-Ground ['Pressurized In-Ground �tt-G ade ❑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(st) ' Dispersal Area Proposed(sf): System Elevation q 0•l 40.•71` <br /> b60 .4 ISOD 1500 utvrtle..'E- °I1.0, 61,1.4. 9.(AL <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u ko". - <br /> New Tanks- Existing Tanks °^-a 2 2 u v m is <br /> G11� pp//�� n.U rn,, rn u.i7 a <br /> Septic or Holding Tank i G� ai6 i AAe.e.C.1.Q .4 <br /> Dosing Chamber L-'t) - t,sj,, 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 ..4--(..„/.. ) --yv 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) /Vf <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIIL County/Department Use Only <br /> 'Approved ❑Disapproved Permit Fee Date Issued Issuing jrtd��ASi```gnatu�re{ <br /> 1 ❑Owner Given Reason for Denial $ ‘. /4t ` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete pleas for the system and submit to the County only on paper not lea than 8 Ma 11 incites in size <br /> SBD-6398(R_Il/I1) <br />