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- ..v;:r:-.,,, County <br /> Safety and Buildings Division Dane 'P <br /> •: B S , _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P S Madison,WI 53707-7162 <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),Stets. L A-v 1 IV A- 20 A 0 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel g <br /> / <br /> 0ciGL 9 11-'75 Gk... t/v l 1</Yl� og CZ— 342- 8002-5-Property Owner's Mailing Address /1 Property Location <br /> 7< a 3 C..1 -VIN4w t✓- Y Govt.Lot <br /> City,State I Zip Code Phone Number t ► t A 1 W t 5l4 lu 1, / A, Section <br /> DCt LA..) r • � �/ T 9 <br /> N: R Q1 E <br /> II.Type of Building(check all that apply) i 1 Lot <br /> �1 or 2 Family Dwelling-Number of Bedrooms ' 4 i I Subdivision Name <br /> Block If <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use <br /> 0[7 8 9 9 5I Town of D A-Ni.r <br /> III.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) <br /> A. iniNew System ❑Replacement System ❑Treatment/Ilolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Change ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> ❑Permit Renewal ❑Permit Revision g of Plumber <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 12 Non-Pressurized In-Ground ❑Pressurized In-Ground ['At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank Either Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) I Dispersal Area Required(sf) Dispersal Area Proposed(st) System Efevation i <br /> VI.Tank Info f Capacity in Total #of Manufacturer <br /> U <br /> Gallons Gallons Units _ r9 `—' <br /> •New Tanks Existing Tanks i .2. 2 s �' <br /> a U 'vt H rn _0 <br /> Septic or Holding Tank a" /„ I 1 V 2 VA/ i x <br /> Dosing Chamber <br /> I <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POSITS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz — 4C4}, 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued issuing ent Signature <br /> Approved ❑Disapproved ___, <br /> ❑Owner Given Reason for Denial S /�/'rJ . t6 -�s . 1C/� <br /> IX.Conditions of Approval/Reasons for Disapproval `�� <br /> I <br /> Attach to complete plans for the system and submit to the County onty an paper not less than 81/2 a 11 inches in size i <br /> SBD-6398(R. 11/11) <br />