Laserfiche WebLink
„ . ' • <br /> County HG <br /> �.': 6 Safety and Buildings Division Dane <br /> <;S 201 W.Washington Ave.,P.O.Box 7 162 y Permit Number(to be filled in by Co.) <br /> S Madison,WI 570 -+71 r <br /> ti•f.. - -;. ;; -.__..__.�.�. 13-20 lc- <br /> Sanitary 6132 <br /> Permit A 1ica ransaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of t is form '(h p �Y l t l u <br /> is required prior to obtaining a sanitary permit. Note:Application forms for st teed governmental unit <br /> the Department of Safety and Professional Servies. Personal information o �POWTS are submitted to 'rojec Address(if different than mailing address) <br /> • in accordance with the Privacy Law,s.15.04(1 m) Stets. y provr e'” k� 4!t+4eP1! �. <br /> I. Application Information-Please Print All Information -- . l ' PF)✓� CGt'.LR,T <br /> Property Owner's Name <br /> 2 P1,14 E LLC (NW OtAJ-Lt ER -I TN'L Z V E R RI) Parcel 0,708- 3a1- (0700-0 <br /> Property Owner's Mailing Address <br /> 5Z! Property Location <br /> VA-1\1- r1.t.(,A i2,l) D R A,V F Govt.Lot <br /> City,State Zip Code P Phone Number <br /> SSE 5 3 of 3 S� % N '/+pse�tion 30 <br /> II.Type of Building(check all that apply) Lot# T 7 N; R 8 E <br /> El or2 Family Dwelling-Number of Bedrooms a O Subdivision Name <br /> Block iE 6 4E2tt.1f b1/coo i2.EST <br /> ❑Public/Commerciat-Describe Use <br /> 0 City of <br /> State Owned-Describe Use CSM Number 0 Village of <br /> ®Town of M, p(,,E..--7 Q1. <br /> IR.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> CgiNew System O Replacement System OTreatment/tlolding Tank Replacement Only 3 ❑Other Modification to Existing System(explain) <br /> B. O Permit Renewal O Permit Revision <br /> Before Expiration ❑Change of Plumber OPetmit Transfer to New List Previous Permit Number and Dale Issued <br /> Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 'Non-Pressurized In-Ground QPressurized In-Ground [JAL-Grade OMound>24 in.of suitable soil [Wound<24 in.of suitable soil <br /> O Holding Tank 00ther Dispersal Component(explain) <br /> OPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdse Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> (goo • `/ /s�‹_i is z g.S-' 8 s ., s <br /> VI.Tank info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units <br /> o y a U U <br /> v v f y New Tanks Existing Tanks n- C 3 .. <br /> U i <br /> in i O C <br /> Septic or Holding Tank q, <br /> Dosing Chamber G I —•• °� N,J�l��!' • <br /> VII Responsibility Statement-I,the undersigned,assume responsibility for installation of the PORTS shown on the attached pleas. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number. <br /> Andrew W Meinholze___ LtJ. NOM 220165 608-831-8103 <br /> Plumber's Address(Street City,State,Zip Code) WV <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuin_ , igna, <br /> S <br /> ❑Owner Given Reason for Denial . 12--! 5 . <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 in x 11 inches in size <br /> SBD-6398(R. 11/11) <br />