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i County ��;� <br /> Safety and Buildings Division Dane I 1•r: 8 s - <br /> x. <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be Rallis by Co.) <br /> P Madison.Wl 53707-7162 <br /> S <br /> � <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 31321(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 {� r�O <br /> purposes in accordance with the Privacy Law,s 15.04(I)(m),Stacy 0-1102.M.0 N� Pow +` <br /> L Application Information-Please Print All Information t� 1 <br /> Property Owner's Name t-/l'µ MC Sb-4'E �y Pa l' <br /> 5PKtl.l C( o 1-4-►G,l-r�..�.LDS CIO Acre Bcot�sj:"5OS- OS1- 00S Go-0 <br /> Li �r.L <br /> Property Owner's Mailing Address Property Location <br /> Z 3.1. > , \\AA IN S i 3ZF--,S-1- _ Govt.Lot 5 <br /> Guy,State 1 ` tp Code Ph. ruvb� f/l` r%t,_Sc„.___;; Section <br /> �I�,J_/.(.4.NIkK F, W 1 I - 59 I T 8 N: R e E <br /> IL Type of Building(check all that app / Lot <br /> Subdivision Name <br /> �1 or2FamtyDwellins-Number ofBed..ms I(" Nt°l� ?oNJD <br /> B.ck= F-1'{-YTS, <br /> ❑Public/Commercial-Describe l� - �'�� ❑City of <br /> R CSM Number 1❑Village of [' <br /> ❑State Owned-Describe Use �tMAY 2 9 2015 (®Town of S e 1Z L NI(rt (F Lin <br /> ��b�` y Co rplete line ft if applinbte) <br /> III.Type of Permit (Check on o B1Lf1 <br /> flvlrtancnea <br /> k i 1 Replacement System I El-free/mewl"lolling Tank Replacement Only Daher Modification to Ryisting System(=plain) <br /> �1\eu•System 1❑ P <br /> II <br /> El of Plumber 1❑Perrnrt Transfer to New I L�Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Remit Revision I( <br /> Before Expiration I Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> \t-Grade Mound>24 in.ofsuitablesol ❑Mound<24 in_of suitable soil <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground <br /> ❑Holding Tank Either Dispersal Component(=plain) ❑Pret rFPtaiu) <br /> V.Dispersal/Treatment Area Information: Area Required(of), -Dispersal Arcs Proppsed(st}••I System f]�tion <br /> I Desi_n Flow(-pd) Design Soil Application Rate(gpdst) i Dispersal/5-4)6 ���, - ;Cr s.� <br /> /� v <br /> TOO Capacity in Total 4 of ._.Nlanufaeturer o I ^ <br /> VI.Tank Info Gallons Gallons Units = . 0 - - <br /> •t..7 Esiaing Tents - - <br /> 1 <br /> I IA 8(o tEC.I 01. 1 Nl1G_lk <br /> , DF >< I I <br /> Septic or-tinkling Tani: ,, A I I <br /> Dosing Chamber 1 (g50 I (P5o I I I -A.t!-t,t�1F I I <br /> T.Responsibility Statement-I,the undersigned,assume responsibility for installation of the FONTS shown on the attached plans. <br /> Plumbers Signature I ivIP/MPRS Number I Business Phone Number <br /> Plumber's Name(Print) n ) - I 220165 I 608-831-8103 <br /> Andrew W Meinhoiz i /t-✓� L <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> 1iii1-County/Department Use Only I Permit Fee Date Issued I Lss-_ Signature <br /> Approved I ❑Disapproved — I 4-/. --. u ` /1 ]mod <br /> ❑Owner Given Reston for Denial S I <br /> DL Conditions of Approval/Reasons for Disapproval <br /> I <br /> Attach to complete plans for the system and submit to the County only on paper not leis than 8 lion 11 inches in sire <br /> SBD-6398(R.11/11) <br />