Laserfiche WebLink
Safety and Buildings Division Dane <br /> z 8 _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S o +` Madison,WI 53707-7162 <br /> b-20\G- ooi1 <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(1)(m),Stats. ,u�L - c tJ �IZ.(�J <br /> I. Application Information-Please Print All Infor talon • � <br /> Property Owner's Name 3a4 s <br /> 3I:F_rzEIv\`( AND S -j'1 A 1)UcK 1t- .-- 0911 - Hz - 0&201 - 0 <br /> Property Owner's Mailing Address n Property Location <br /> 3 )S 0El-so R <br /> ) omD • Govt.Lot <br /> City,State � N Zip Code Phone Number 1/ E V f4 NIA)114, Section '1 <br /> N �� <br /> SUN) ►z!wt IZ.1 Et J( — f I T 9 N: R ( I E <br /> IL Type of Building(check all that apply) Lot'. - <br /> �I Subdivision Name <br /> a1or2 Family Dwelling-Number ofBedr ems 1/' <br /> Block# 1\1C)LO 'f ROM) g TAI-- -9 <br /> ['Public/Commercial-Describe Use 0 City of <br /> CSM Number ❑Village of <br /> ['State Owned-Describe Use f2-1 S T lr <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line,B if applicable) <br /> A. 'New System ❑Replacement System ❑Treatinent/I-Iolding Tank Replacement Only ['Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date issued <br /> B. ['Permit Renewal ❑Permit Revision ❑Change of Plumber I lPermit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> LNon-Pressurized In-Ground ['Pressurized In-Ground at-Grade ❑Mound>24 in.of suitable soil ['Mound<24 in.of suitable soil <br /> [J Holding Tank ['Other Dispersal Component(explain) []Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soppilfication Rate(epdst) Dispe Area Required(sf) I Dispp l Area Proposed(si) System Elevation / i <br /> LIj2,0 � ,i Sao /��v /1 9‘.5 96-3 <br /> VI.Tank Info , Capacity in Total #of Manufacturer L J <br /> Gallons Gallons Units _ <br /> ^.. b J w J j V <br /> New Tanks E\atine Tanks 3 ^ 3 = = _ <br /> =U tom 55 .O <br /> eetic or Holding Tank I �) Q (i ,*'4* F. F � ( I <br /> Dosing Chamber / 60 {oLU I' So , +'' , ,', I WA/�j,c / r <br /> VII.Responsibility Sta ement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz l v.--�y- 220165 608-831-8103 <br /> Plumber's Address(Sc tret,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only . , <br /> Perm' Fee r/ Date Issued lssui :A, igrta i� <br /> Approved ❑ Disapproved I s / 3/ �� 1 <br /> A. <br /> ❑Owner Given Reason for Denial 7 6 ` `-..' <br /> IX.Conditions of Approval/Reasons for Disapproval 1 <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/Il) <br />