Laserfiche WebLink
-- County <br /> Buildings Division Dane '` <br /> r 11� 1 ton Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 0 _ <br /> so - Madison.WI 53707-7162 (3 -26(C- oo l3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 1, <br /> purposes m accordance with the Privacy Law,a.15.04(IXm),State Tb\�PI{J }-AirL- g0.41) <br /> I. Application Information-Please Print All Informal <br /> Property Owner's Name e � 4.1 e2n i Pared <br /> RI -M 5CNULtEN—RICN-a2v ►s4aR - ALexA .z cGt Zsai3 0&to'7-Zt3- 8'746-6 <br /> Property Owner's Mailing Address / Pro -Location <br /> 2343 TOWN 4.1-x-R.oaa Govt.Lot <br /> City,State 1�]1,�-. Zip Code I Phone Number may, _ y,,Section 2. <br /> 1.0- 4012e_B 1c/1 535'721 T____N: R 7 E <br /> IL Type of Building(check all that apply) .Lott- <br /> } i1''3 (.�'. I Subdivision Name <br /> �I or 2 Famly Dwelling-Number of Beldrlt<tms �1 i y I. <br /> / Block d <br /> El ,PublidCommt rcial-Describe Usc '' , i <br /> i MAY 1 2 ?J15 1 1:1 City of <br /> J I C5M'Number �❑Village of <br /> ❑State Owned-Describe Use I esl Towm of S P RI N Gn.O A-LE <br /> s ►;3932 <br /> III.Type of Permit (Cheek only one Sox on line A- Complete Iine-B-ifapplieable) <br /> A. New System ❑Replacement Systan ❑Treannent/llolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. List Previous Permit Number and Date Issued <br /> ❑Permit Renewal ❑Permit Revision CI of Pltanber I❑Permit Transfer to New <br /> Before Expiration I Owner <br /> IV.Type of POVITS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑PressurizcdIn-Ground -Grade fiMound>24 in.of suitable soil 0 Mound<24 In.of suitable soil <br /> El Holding Tank ❑other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Arcs Proposed( I System Elevation <br /> Design Flow(gpd) Design Soil Application Rate(ggpdsf) 1 Dispersal Area Required(sf) I Dispe sal�QO Il SET��s'l-rlC 1 <br /> 450 <br /> VI.Tank Info Capacity in Total 4 of Manufacturer n t <br /> Gallons Gallons Gallons Units _ _ _ <br /> Now Tanks Existing Tanis i? o 2.E . — <br /> —U i v: —v <br /> -7.5-c•/300 �r' y { �7� I ~ <br /> Sepdc.rtladsa Tank j 4 f�OD 1 _ 1�/f Tom`V- JI <br /> Dosing chamber (f/0 a LeO I NSF °E <br /> VII.Responsibility Statement-I,the undersigned,assume responsibiLty for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> — / 220165 608-831-8103 <br /> Andrew W Meinholz �C. 6✓. � '"T1 <br /> Plumber's Address(Street,City,State,Zip Code) fl_) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> .County/Department Use Only �� <br /> reffnit/ 7F(e�e//_ Date lssuncd Approved I❑D spproive /L 14 �i --/ l / b� <br /> ❑Owner Given Reason for Denial 11 <br /> IX.Conditions of ApprovaVReasons for Disapproval ' �� ����� <br /> PR97 - � —G.R4..DE Af7 7E A4'9 � /Sr r--Lee�J <br /> 1-' 'A, f9IG cofya9<--(io f*(G E--re-c4{//��aY/ i^30 l'E-eto,444 T <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8[r2 z ll inches in size <br /> SBD-6398(R.11/I l) <br />