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County <br /> 8 Safety and Buildings Division Dane <br /> S o 201 W.Washington Ave.,P.O.BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> I z015 0� <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),Sorts. //� <br /> I. A..Ilcntion Information-rime Print All Information lJf�p ��Q c 1 !� A d a <br /> Property Owner's Name <br /> CYLI STY F1-LEA Parcel: <br /> �os-r- 12 <br /> i2 0'7 CO - 1 (31 - 8o(0.7-- <br /> Property Owner's Mailing Address d <br /> Property Location GIP-ZEN VvA Y ou�EV,q r�o 30� <br /> Govt.Lot <br /> City,State <br /> Zip Code + Phone Number N� <br /> MI uue,E�� VA 535(02 I %� N E 1/4, 1 <br /> II.Type of Building(check all that apply) Lot= T 7 N: R 3 E <br /> 21 or 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name <br /> RECEIVED Block <br /> ['Public/Commercial-Describe Use <br /> ❑State Owned <br /> In City of <br /> ned-Describe Use JUN 18 1015 CSM Number ❑Village of <br /> 109 30 aTownof M 1p f Ll.TO <br /> III.Type of Permit (Check only tiapAmegmplfte line B if applicable) <br /> A. <br /> Kg New System ❑Replacement System ❑Treatment/I•lolding Tank Replacement Only <br /> ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal <br /> I <br /> I <br /> ❑Permit Revision ❑Chanee of Plumber I['Permit Transfer to New I List Previous Permit Number and Date Issued <br /> Before Expiration <br /> I Owner I <br /> IV.Tyre of POWTS S stem/Com.onent/Device: (Check all that a.81 ) <br /> ®Non-Pressurized In-Ground ['pressurized to-Ground DV-Grade ❑vlound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> g <br /> Holdin <br /> Tank <br /> ❑ _ ❑Other Dispersal Component ponent(explam) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) <br /> Dispersal Area Proposed(at) System Elevation <br /> (0;_______;::(___f) L/. /5_ 7-C, 2 , yamp 0. biMO <br /> VI.Tank Info Capacity in Total of Manufacturer • <br /> Gallons Gallons Units .... p I =- <br /> NtwTauks f Gcistins Banks 1.1). r - <br /> J <br /> Septic or Holding Tank 'oZ�i(.P 1 - I tiLZAOI- I X I - <br /> Dosing <br /> Chamber c.5Q I (yd I I NiMADF I I <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POIVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sianaturc iVIP/MFRS Number Business Phone Number <br /> Andrew W Meinholz <br /> / �- Gt.,. -�� 220165 608-831-8103 <br /> Plumber's Address(Street.City,State,Zip Code) <br /> • <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> / uProved ❑Disapproved Perm' Fee DDaetc IIsssued Issuing Agen .grta t <br /> ❑Owner Given Reason for Denial S t'+ ((y l�y/s <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Ia s 11 inches in size <br /> SI3D-6398(R. 11/11) <br />