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County i Safety and Buildings Division Dane r 'LDS _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) °S Madison,Wi 53707-7162 f 3 - 7°6- eb ( 3C • Sanitary Permit Application State Transaction Number In accordance with SPS 38;31(2),tests.Adm.Code;submission of this farm m the appropriate governmental unit 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) the Department of Safety and Professional Sevin. Personal information you provide t rat be used-orsecondaw __ purposes in accordance with the Privacy law,s_13.04(1)(m).Stars S I. Application Information-Please Print AB Information 5 'r�?A RKE2 PASS Property Owner's Name y'Parcel: Vat lvt,sc u ( a,n,e.y 1---L,C. MAY 1 2 2015 P9 II - J 3 — 0100-0 Property Owner's Mailing Address ,popery Location 4 Lez 1 C>Ae C tzar tens Cl tZ F -- - :- __—Govtiot City,State I Zip Code I PhoncR turnbcr _ r.ISLE 10-,LE-ST G1,1I 15353 Z 1 T 9 N: R t E IL Type of Building(check all that apply) t Lot'- ®I or 2 Family Dwelling-Number of Bedrooms -4 I to Subdivision Name I Blocke PAR.v.E.Rrs :PLACE CI -Descnbe Use ❑City of QState Owned-Describe use I CSM Number El Ville of I 'E Town of r"n 7R.)S?LPL I III.Type of Permit: (Check only one box on tine A. Complete line B if applicable) j A. New System ID Replacement System I❑Treamtenalold"ay Tank Replacement Only i QO'Jtcr Modification to]:misting System(explain) I I �---t_ ' i B. F Permit Renewal 0 Permit Revision I Oa of Plumber t�t�errntt Transfer to Now I List Previous Permit Number and Date Issued i fore Expiration I Owner 1 IV.Type of POWTS System/Component/Device: (Cheek at-Grade that apply) ((( 0Non-Pressuized��In--tlGrwmd DPressurized In-hound DAt-Grade �ielound>24 in.-of__suitable soil ❑Mo Mound<24 in.of suitable soil 0 Holding Tank DOther Dispersal Component(=plain)_ t_N.111.dtuc..nt Device(explain) al-AT Si rE V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) 1 System Elevation ceo0 a6 ! 1 1.3.06 fi VI.Tank Info Capacity in Total 4 of Manufacturer a s L Gallons Gallons traits ..E j= - NcvTaulS i Esining Tants o E a - _ ( ,e_ _a-U r m c v Septic a.iie(Efny`1'aak ' (°`'C)L 1 [.2.8•t, Z I titE A-D£ X ' Dosing Chamber r te 50 ' — (Bo, 1 I t#1 E4DC_ X 1 1 , VII Responsibility Statement-I,the undersigned,assume responsibility fbr installation of the POVI TS shown on the attached plans. Plumber's Name(Print) ' Plumber's Sipame I MP/A4PRS Number I Business Phone Number Andrew W Meinholz i Gv• , 220165 1 608-831-8103 Plumber's Address(Streit,City,State,Zip Code) 6813 County Highway K,Waunakee WI 53597 VV VIII.County/Department Use Only Permit Fee �� Date Issued 7 Issuing Agent / APProved ❑Disapproved I S ) 7 L 6 -I 5-1-17 2-07 C r�CTI 61.kr- � S ❑Owner Given Ru-son for Diva! IX.Conditions of Approval/Reasons for Disapproval �i�0 A�A- lr i r Pi yf f .oFF � PO-Mc-7 wrr� ,yr7 n7F /f✓�'7' NrouC /L -r-,44--fecr Attach to complete plats for the svttn and submit to the County only on paper not less than 8 lax 11 in hes to six SBD-6398(R.li/Il)