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County <br /> !:--- ;. RECEIVED Safety and Buildings Division Dane <br /> .. 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.)• <br /> :"' g� Madison,WI 53707-7162 <br /> •:,,, . Jul 7 2015 1,3 - 2015-- 062zq <br /> FFny1P �N{Ca alt Application State Transaction Number <br /> In accordance w h SP530S3` (2),tk'is.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior •obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department•f Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in acco •ance with the Privacy Law,s.15.04(I)(m),Slats. L ���$UCH LA <br /> I. Application Information-Please Print All Information • <br /> Property Owner' Name Parcel Li <br /> PAut..-5 D E V M T e.Lop , LLc, 091 - t 3- (5t9- o <br /> Property Owner' <br /> 517121N-61S n�er' Moiling Address Property Location <br /> '1 t0(J ! OAK C uuu,G -E Govt.Lot <br /> City,State Zip Code Phone Number <br /> S E '/a, Sid VI, Section 1 <br /> D . • c$r ,VJ I 3 2 T 9 N: R 11 E <br /> II.Type of Bu ding(check all that apply) a Lot u <br /> g or 2 Family swelling-Number of Bedrooms ( -1 1 Subdivision Name <br /> Block# 'l_. <br /> ❑Public/Comm• iat-Describe Use c,r of <br /> ❑' <br /> CSM Number ❑Village of <br /> ❑State Owned Describe Use <br /> IA 0Q0 NtTown of 8 R(STC31— <br /> M.Type of Pe m it: (Cheek only one box.on line A. Complete tine B if applicable) <br /> A. ®Nett S tern ❑Replacement System ❑Treatrnent/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) J <br /> I <br /> �1 <br /> List Previous Permit Number and Date Issued <br /> B. El Permit enewal 111 Permit Revision ❑Change of Plumber 0PermitTransfer to New <br /> Before Ex iration Owner <br /> I.V.Type of P r TS System/Component/Device: (Cheek all that apply) <br /> NINon-Pressuriz d In-Ground ❑Pressurized In-Ground at-Grade [Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank DOthcr Dispersal Component(explain) Pretreatment Device(explain) <br /> V.Dispersal/T i eatment Area Information: <br /> Design Flow(gp.t Design Soil Appli(caation Rate(gpdst) Dis�peerrsall Area Required(sf) Dispersal cArrea Proposed(st) System Elevation Qp 41E i <br /> c <br /> VI.Tank Info Capacity in Total y of Manufacturer o <br /> Gallons Gallons Units - °� O ' <br /> J U j 3 g V: <br /> nta <br /> New Tanks f Existing Ta ."? ^ = = — <br /> Septic or Holding T•k ' /-8 _ I '.28'o -2 14 Q E I /1 I <br /> I.U I <br /> Dosing Chamber 5 t(0/ C950 (: a l F De I x I I <br /> VII.Responsib lity Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name 'riit) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W M:inholz [„>. 220165 608-831-8103 <br /> Plumber's Addre•-(Street,City,State,Zip Code) <br /> 6813 County ighway K,Waunakee WI 53597 <br /> Viii.County/1 epartment Use Only <br /> Permit Fee Date Issued Issuin/Agent Sian. �' <br /> `I6LRpnroved 0 S / D, I 7 /1 <br /> 1 It i!/ `z <br /> ❑Owner Given Reason for Denial O I . -- c <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 S tax 11 inches in she <br /> SBD-6393(R. '1/11) <br />