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/ $ County Safety and Buildings Division Dane ,n-H 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) Madison,WI 53707-7162 1/6-2.Q1s` 10\ Sanitary Permit Application State Transaction Number ice with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) nent of Safety and Professional Servies. Personal information you provide may be used for secondary accordance with the Privacy Law,s.15.04(1)(m),Stats. Es K e_R„—AKA l L ation Information—Please Print All Information vner's Name h(1 IZS ' Parcel# 1LSC3h) DeVeL O P h�f✓ U--C c Re c►-� o r�tc.y ') ' ii — 1.2,1 - 0131 - O vner's Mailing Address Property Location rl OAK_5 p 21 14.61 5 C I IZCt,F Govt.Lot ..... Zip Code Phone Number Ni _ '/4 Ni a 14, Section . I,2.. -G t2.e_si- Vt./ 1 "--53-'5 3 2 T 9 N; R I I E f Building(check all that apply);f ^ Lot# milyDwelling—Number of Bedrooms, " 4 5 ' Subdivision Name Block# DR U MU.IV C1C5, .-k. )mmerciat—Describe Use ❑City of ned—Describe Use CSM Number ❑Village of 54 Town of B R t STO L.. f Permit: (Check only one box on line A. Complete line B if applicable) ew System C Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) :rmit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued e Expiration Owner f POWTS System/Component/Device: (Check all that apply) surized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil Mound<24 in.of suitable soil 'ank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) _ it/Treatment Area Information: (gpd) Design Soy/Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation 6. /C- V 6, s''/ JUU t /3So S.f C"..5,afo Capacity in Total #of Manufacturer Gallons Gallons Units 0 o-0 New Tanks Existing Tanks 5 .a a r� Q q� �r a.C) vs y rn _r. O i. ngTank I . -2 (, _ _ f/a`_Na - NLi ra�� - er (�5 O V5o I Meprn E_ X asibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. ane(Print) Plumber's Signature MP/MFRS Number Business Phone Number Meinholz 4.-- .LA)_ `Tt--► 220165 608-831-8103 {dress(Street,City,State,Zip Code) ity Highway K, Waunakee WI 53597 . /De•artment Use OnI / Permit Fee Date 1 sue¢ Issuin ' �'' ❑ Disapproved S y �� i '4 ' i t� Iy/ r (--- ,/� ❑Owner Given Reason for Denial ) l �aJ _� ��"—a- � — ons of Approval/Reasons for Disapproval �, illiii . I Attach to complete plans for the system and submit to the County only on paper not less than 8 llz x II inches in size . 11111)