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County <br /> Dane 1__L <br /> Safety and 13uildmgs Division <br /> 3i Wet&n. 201 W.Washington Ave.,P.Q.Boa 7162 sanitary permit*mks(to be Rlkd in by Col <br /> i> • Madison,WI 53707-7162 7162 <br /> �._: 13 -2.015- 0023q <br /> Sanitary Permit Application State Tnntsection Number <br /> in accordbnm with SPS 353.21(2),Wis.Ado.Code.submission of llik fa no to tbceam:late govvnmatlal orb <br /> is required prior to obtaining a=dory panel Note Appiimilm fonts for stole-owned POWfS me submitted to Project Address Of diffcemni an mailing alkltnt) <br /> Ike poses Department of once Safety w th and he Professional L wachs Personal Stsos. l :a tt 6e I V Ese��ory <br /> the (n attordance with the of essio taw,s s..0Person l Slats LCI gU� 2581 Highway 92 <br /> 1.Application Iniornisdon-Please Print All Informetien <br /> Property Owner's Name Pared I <br /> Z&L Properties LLC . JUL 2 3 2015 0606-131-9910-0 <br /> Property Owner's Mailing Addw Property Location <br /> 8854 Offerdahl Road Pubsc Health mix Envjmn Govt.Lot <br /> Cdy,State Zip Code PitonenintOl Haatth SE N, NE w,section 13 <br /> Mt.Horeb,WI 53572 ( a'a) <br /> T 6 N; it 6 EorAt <br /> H.Type of Building(check all that apply) Lot I <br /> ❑I ar 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name <br /> Block Y . <br /> ID pu6gc/Cananecaw_Dearibe the Contractor Shop/Office ❑city or • <br /> ❑Siete Owned-Describe Use CSMNatnbv ❑Village of <br /> 13959 IB Town or Blue Mounds <br /> III.Type f Permit(Check only one hat on Ike A.Complete line B fiappfcable) <br /> A. New System ❑Replacement Syska ❑TrtxPolmUHokHngTank Replacement Only ❑Other Modification to Existing System(=plain) <br /> B. ❑Permit Ralewal ❑Permit Revision ❑Cbage of Pkmober ❑Nina Ttmarer to New list PrevO iu Paral Nianber and Data issued <br /> Before Expiation Owner <br /> IV.Type of POWYS System/Component/Devica ( ail that apply) <br /> ❑Non.Preuowbzed In-Ground ❑Pr r lo-Ground y�At Oatde ❑Mood>24 is oCsndleble sail ❑bbomtd..a24 In.of sagabk sad <br /> ❑Holding Tank ❑Other Dispms;Component(espbdn)/ ` ❑Pretreatment Device(cxplain) <br /> V.Dispersal/Treatment Area Information: <br /> Design n9v ignd) Design Soil Application Rare(gsie9 Dlspcscl Area (si) Dtspasel Area or) System Ekwtica <br /> 'S3■?\_, 0.6 " ft' lid 100.5' <br /> VI.Tank Info Capacity in Gallons Units Maw' <br /> I <br /> / <br /> e <br /> Noe T n yam? <br /> Tanks Ea ti,:Tanks , or w 1C 2 O w <br /> Septioorlr.Id'ogTalk 1000/300 . 1300 1 Dalmaray x <br /> bonus ao bar 600 600 1 Dalmaray x <br /> VII.Responsibility Statement-I,the undersigned,assume respond6Uity for intonation of the POWTS shown on the attached plans. <br /> Pimnha'a Name(Print) Plumber's Signature MP/MPRS Number Busloces Phone Number <br /> ` '- ry ede ° -i S S 60S-9`15-7V‘-6 <br /> Plumber's t Sale,Zip e1 <br /> 133O � ■■ Q■ . Vr2rov� (A.)- ... 5359-3 <br /> VI Connty/Department Use Only <br /> ❑Disapproved s I(•eye/f�_�� Dnta Issued lancing <br /> ❑owner Green Reason Rs Denial � s V - rS <br /> IX.Conditions of ApprovnlReasons for Disapproval <br /> Attack to rmaple.plan far Ihe system use admit to Ike Canny rely on paper not her We a to a 11 faekes la site <br /> SBD-6398(R.11/I 1) <br />