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r t,•�i::.ari,r. RE\ Ei V a. Ll County <br /> and Buildings Division Dane <br /> `z O . _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S p SEP 0$ 2015 Madison,WI 53707-7162 /� <br /> s 1-5 _2d1S— 6°285 <br /> ` Public Health MDC <br /> Sane 1y 1erxfille A 'plication 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(1Xm),Stets. <br /> Cs LO LA N <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name C/0 M A IZTE.t4 B 1,1,11.01 ‘ Parcel# <br /> PAut sol j bE,VeLoemeNIT 4 K ID es14.4 • 09 II— 194- 460c3-O <br /> Property Owner's Mailing Address (140aL 1.11 t-5.. u/ at.LD K41( ) Property Location <br /> Pa Box (0 4 O t L.3 .r-- ) Govt.Lot <br /> City,State Zip Code Phone Number S ka 1/4, s c 'n, Section 1 9 <br /> Srw P124-f 12..1 iE V..1 1 53 5 9 (i T 9 N; R I I E <br /> IL Type of Building(check all that apply) Lot# <br /> NI or 2 Family Dwelling—Number of Bedrooms A .10 SubddivisionName /� <br /> Block# L >r ivi4 MMI�S ADorJ <br /> ❑Public/Commercial—Describe Use 0 City of <br /> QState Owned—Describe Use CSM Number 0 Village of <br /> Town of BIZ,is Tr)L- <br /> III.Type of Permit: (Check only one box on tine A. Complete line B if applicable) <br /> A' ININew System ❑Replacement System ['Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision List Previous Permit Number and Date Issued <br /> ❑Change o Plumber Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground QPressurized In-Ground QAt-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank ElOther Dispersal Component(explain) Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(si) System Elevation , / <br /> ILO r V /S"o /t -/ Z 107• 3/ fe. 6 <br /> VI.Tank Info 'Capacity in Total #of Manufacturer <br /> Gallons Gallons Units _ <br /> New Tanks Existing Tanks u = m„ a H <br /> Septic erl4eldiasTank 1 ` e _ /_ te, K. <br /> Dosing Chamber `dI_5UO4o 6;Litt'5sdp 1 1‘41044(1)ta ✓” <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature i MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz c._ GtJr ---' o 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Per it Fee Date Issued lssui ant ign.yi <br /> ❑Owner Given Reason for Denial VI/6U 1�y <br /> L._. t44.4.3-- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> I <br /> I <br /> Attach to complete plans for the system and su,,mit to the County only on paper not less than 8 V2 z 11 Inches in size <br /> SBD-6398(R. 11/l 1) <br />