DCPZP-2015-00439 - Laserfiche WebLink

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,. _ : RECEIVED l co..:Safety and Buildings Division I Dane - i - i s n - - MAY 2 6 2015 1 201 W.Washington Ave.:P.Q.Box 7162 ! Sanitary Permit Numb&(to be Idled in by Co.) Madison,Wi 53707-7162 Public Health MDC l',,,L'„t.��l., t,-�»E\4L._ Fnvirnnmental Health Sanitary Transaction Number Sanitary Permit Application I In accordance with SPS 3031(2),Ms_Adm.Code,submission of this form to the appropriate governmental unit 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) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ' I purposes in accordance with the Privacy Law,s.I5.04(1)(m),Stars. I rl (ii,1 PAPL6 y Dewy_ 1. Application Information-Please Print All Information Property Owner's Name /n� . Parcel_'- .k C)Yjr(Li Frt..l4) f-�'14u SGt D t.Nt_09,� G9or-/- 0t4- Oaci- 5 Property Owner's Medina Address Property Location 3C-a(4 I C E- A c D RAve Govt Lot City,State I Zip Code I Phone Number k %,a _'=4.Section_i_- 01,A-DiSoN W I I 53 1 19 i T g N_ R I E 1 If,Type of Building(check all that apply) Lot_ ( - 741Ior2 Family Dwelling-Number ofBedrooms A I Snhn7n"ci„nName C- I-� Blocka 1\44-E--""T 5 A-0 D B t!.Q3 1 Public/Commercial-Describe Use _ ( I i I,❑7 City of I J CSM Number '!_t Village of �-y State Owned Use I®Town of IUxeuK.Y III.Type of Permit (Check only one box on line A. Complete line B if applicable) A..• New System I❑Replacement System I QTreatment/FIolding Tank Replacement Only I t 00ther Modification to Bxisting System(explain) I 1 B. D Permit Renewal ❑Permit Revision I El Change ofPltmber 10Pernit Transfer to New I List Previous Permit Number and Date Issued Before Expiration I I Owner ! IV.Type of POWTS System/Component/Device: (Check all that apply) ['Mound RNon-Pressurized In-Ground QPressurized In-Ground DV-Grade LiMound?24 in.of suitable soil [Mound<24 in.of suitable soil CHolding Tank ['Other Dispcaal Component(explain) ['Pretreatment Device(explain) V''Dispersal/Treatment Area Information: Desim Flow(gpd) I Design Soil Application Rateiepdst) l Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation / Ce00 ! , y I /S.-oo ' /- ac) I /00-`7' /g, V'.Tank Info Capacity in I Total _of Manufacturer - Gallons Gallons Units i _ _ O J _ Non Tattle I Existing Tanks I c_ 3 _ u _v = Yl p 1 f I 'E.dJ i .r .A ! a y Septic or Holding Tani: I I,g_ ./n I It.I_/T Co I <4- I 'v L A-012 I L4 Deising Chamber I I 4- I _ I,c i I I.Responsibility Statement-I.the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Pl bet's Name(Print) Plumber's Sianoture MP/PRS Number Business Phone Number drew IN Meinholz W Y� 220165 608-831-8103 i PI bet's Address(Street City,State,Zip Code) 6 13 County Highway K,Waunakee WI 53597 VIII.County/Department Use Only �,/ I Permit Fee Date Issued I Isstinc t Signature %Approved I❑Disapproved :)j_..,,,,., y -'S.,—':-71.-l--'" '.. 5-Ti8-Is-I !/1 t e ❑Owner Given Ru-tion for Denial I g j IX_Conditions of Approval/Reasons for Disappr val on pp `�'40 9.co Attach to complete plans for the system and submit to the County only on paper not less than 8 to c II inches in she 380-6393(R.Il/il)