Laserfiche WebLink
;e,•n_ru�i.y., County , <br /> ,f„'. \� <br /> :', Safety and Buildings Division Dane <br /> ai 201 W.Washington Ave., P.O. Box 7162 <br /> 1,0 S ' 'ice} g Sanitary Permit Number(to be filled in by Co.) <br /> _� P S wi Madison,WI 53707-7162 <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 /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stats. M 101\11611.-IT S u N D 12.1 v f✓ <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 1./'' TO>D A-NAD IVtA-g.SN-A Scv+r, osi<R ..-----69 it - 191 - ate(• 5 -0 <br /> Property Owner's Mailing Address Property Location <br /> aaO CAA-t2.pIry bttwE. / 4$r. 3 Govt.Lot _ <br /> City,State ,.Zip.Zip --- Phone Number <br /> 31.4N P R. -I 1 E. W I r' 53 S 9 J0 �� _'/`' N k '/4, Section (9 <br /> U.Type of Building(check all that apple Lot# T g N; R I( E <br /> ►,1or2 Family Dwelling-Number ofItedroorns /,. ' el 5 /Subdivision Name <br /> •-........------- <br /> -........_ Block# 1 of &i A C I RO A-0 _ <br /> TA-TES <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number <br /> a❑�Village of <br /> l Town of B K i S f ot-. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. X]New System y ❑Replacement System ❑TrestmenVFiolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision ❑Chan a of Plumber List Previous Permit Number and Date Issued <br /> g QPermit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground OPressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑Holding Tank [baler Dispersal Component(explain) OPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design_Flow(gpd) Design Soil Ap 'cation Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> loO . 0,C, 1 I1-C ` l J 0 0 (-1c\.0 <br /> VI.Tank Info Capacity in otal #of Manufacturer <br /> Gallons Gallons Units Fy a <br /> P V <br /> New Tanks Existing Tanks , c Y <br /> j U h rn �0 .. <br /> a:0 LL <br /> Septic or Holding Tank 1 ;1 p /„ IA(5(A' a A, -A O i X <br /> Dosing Chamber (�j_5V`0+ (15o ) 1 M1, E r O <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P tuber's Si tureen MP/MPRS Number Business Phone Number <br /> Gary A Meinholz 222318 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) —,_,-,--- <br /> 6813 County Highway K,Waunakee WI 53597 . <br /> VIII.Coun /De•artment Use Onl <br /> t= •pproved ❑Disapproved Permit Fee Date Issued ' Issuin. gen Si _s�r�,�-� <br /> ❑Owner Given Reason for Denial V31 — 4 - Al ' <br /> ... . . <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> U c.v i- <br /> - 'VI - rl°��, c ' 7� RECEIVED <br /> U4 �( +' y APR 08 2015 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1!2 x 11 inches In aizo <br /> Public Health MDC <br /> SBD-6398(R. 11/I1) Environmental Health <br />