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ran-,rH- County �..rr` <br /> .\ l <br /> "-•• Saf 'e.•r 14 ly . - r .fl IN } <br /> •y'. 201 W. n ' , -! ; • Sanitary Permit Number(to be filled in by Co.) <br /> = ` II �'-1 •' $ — 1•• <br /> %-(r. �s '; JUN 2 2 2015 1y26IS-OO2O0 <br /> Health MDC State Transaction Number <br /> Sanitary Permit Appli . .ti • ental Health <br /> In accordance with SPS 38321(2).Wis.Adm.Code,submission of this form to. e 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 Servits. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stan. SA M� <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> _ , , : . -, 1 k - - o12/a911-r94- 46710-2 <br /> Property Owner's Mailing Address , 'L �-S1 U S Property Location <br /> - -R 9' ' Mr ,, 5F#2,7,4. g�1.u, 1 K- G°C. Govt.Lot <br /> p <br /> City,State Zde Phone lumber S E r',,S F t/a, Section 1 <br /> SUN PaAr1-12.1,E 1 `-90 l T , N; R ( I E <br /> II.Type of Building(check all that apply Lott? • <br /> +�" � Subdivision Name <br /> ol.sr 2 Family Dwelling—Number of Bedrooms j <br /> T _ Blocks P ..1313(..E V Au y <br /> O public/Commercial—Describe Use 0 City of <br /> CSM Number 0 Village of <br /> State Owned—Describe Use <br /> 0 Town of Ble.I STt L <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. ONew System O Replacement System OTreatment/Holding Tank Replacement Onl Other Modification to Existing System( sin) <br /> B. List Previous PermitNumber and Date Issued <br /> ❑Permit Renewal ❑Permit Revision ❑Change of Plumber permit Transfer to cw� <br /> Before Expiration Owner "--•-_°'-`"------ <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> Pah s' lon-Pressurized In-Ground OPressurized In-Ground [JAt-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in_of suitable soil <br /> O Holding Tank DOther 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(si) System Elevation <br /> • Capaci 1rlJ� Total g of Manufacturer + <br /> VI. <br /> Tank Info Capacity•in I <br /> Gallons Gallons Units �, § o'° <br /> o `' "' n <br /> New Tanks Existing Taal t °o 2. iz a .8 0 m <br /> �- A, C.O rn y cis W t7 n. <br /> /mac Holding Tank /()CC) I t G I / A -A.4.S._. <br /> Dosing Chamber 5e0C) I i. _ 1 f t t - <br /> VII.Responsibility Statement-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 to -�,.�� 220165 608-831-8103 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only _ <br /> roved ❑Disapproved $Permit Fee Date Issued Issuin gent Sign: c�� / <br /> — It r, <br /> ❑Owner Given Reason for Denial a .t jig ;� �/�i __ �a t <br /> IX.Conditions of ApprovaUR s for Disa vial •f, 4e,' �'e�_ . 1 .- y <br /> VJA_ 77154atk-( /V41:TagaiMMEStiVVVQ4.4eLli,CIZA)E-P-N5 - -1 eCj <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in r 11 inches in size <br /> SBD-6398(R. 11/11) <br />