Laserfiche WebLink
County <br /> Safety and Buildings Division Dane r ! 1 <br /> D S 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) j <br /> r S Madison,WI 53707-7162 <br /> "-- 12)"2C)IS— \2_ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 333 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(1)(m),Stats. S(-+I M MIT g I b 6E ROAD <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> 001\11C'.,A AN I) I<E(.1 J4CV1 Nb9 or7OS -Osa- PA SO— o <br /> Property Owner's Mailing Address Property Location <br /> t 511 S 40o-n NCI STAR, AVENUE Govt.Lot <br /> City,State Zip Code Phone Number <br /> kt P1 ID I�L1t") 1 53 5(o Z � vi,��`/• section �j <br /> _ T 7 N; R a E <br /> II.Type of Building(cheek all that apply) Lot# <br /> ©Ior2 Family Dwelling—NumRo�8e 2. Subdivision Name <br /> L({{..•..�.• Block# '- <br /> ❑Public/Commercial—Describe Use <br /> MAY 0 6 2015 El city of <br /> OState Owned—Describe Use CStiI Number ❑Village of <br /> Public Health MDC (2'7 2E5 KI Town of Ot I DM,C, Tate <br /> Environmental Health <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. rgi New System Y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision List Previous Permit Number and Date Issued <br /> El of Plumber Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> (2 Non-Pressurized In-Ground OPressurized In-Ground QAt-Grade OMound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> OHolding Tank OOther Dispersal Component(explain)_ OPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation / , <br /> 150 , v i 2 ; 5 e; �4is- P. . <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units °o v B <br /> New Tanks Existing Tanks . g . u a`i 4 i, <br /> i o r <br /> ^ —(U in y r u,p C. <br /> Septic or Holding Tank I/-1050 1 -/-- M EA-13 /1 <br /> Dosing Chamber 1.0 tt."....Y NiteilaPi 153249' 'SIMI <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POII''l'S shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz __,...eLe._ 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) . ----‘"? ..27) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing nt Signature //�/ �,//� <br /> ❑Owner Given Reason for Denial S" ! � <br /> .5:12-�S /// k a_/�" <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1r2 x 11 inches in size <br /> SBD-6398(R. I l/l l) <br />