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County <br /> Sefcty and Buildings Division Dane <br /> ii S - - 201 W.Washington Ave-,P.O_Box 7162 Sanimty Permit Number(to be filled in by Co_) <br /> ti P S = Madison,WI 53707-7162 <br /> 13 -2415 oo2 ,8 I <br /> I Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38311(2),Reis-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 POINTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional s 1 Personal information K wt y <br /> purposes in accordance with the Privacy - 5-04(I m Stats. US H w a <br /> 5 (Application Information-Please Print All information <br /> Property Owner's Name Parcel s <br /> E t .l.0 A-YL()" y SC 44 1 t-r r SEP 0 8 16 ! O Ca)U— .D-a-I aSCG-9 <br /> Property Owner's Mailing Address Public Health MDC Property Location <br /> 24217 Tow 120 A D Environmental Health Co Lot <br /> lettate <br /> C I ► s►�L¢�'1� D I COde <br /> SS I Phone Number KRA''iy !I.E %,Section ,a.,- <br /> 1l f <br /> IL Type of Building(check all that apply) Lot= T N: R l a E <br /> 14l or 2 Family Duelling-Number of Bedrooms Subdivision Name <br /> Wv I Block;, 1w IV-S' PSr\Jl) 43 cAdk)a]4 <br /> DPublit/Commcrcial-Describe Usc <br /> i <br /> ❑city of a <br /> DSlate Owned-Descrlbc Use <br /> CS Number D Visage of <br /> [Town of D LL N r\J <br /> IIII.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> IA. ZNew System 0 Replacement S3stmr !DTrea m. em/tlolding Tank Replacement Only I Dolor Modification m Existing System(explain) <br /> I i I <br /> IL <br /> [I Permit Renewal ❑Permit Revision ❑c"...-ofPlumber IDPermitTransfertoNew I List PrimlOUS P Number and Dale Issued <br /> BeforeEspiration I Owner IIII <br /> IV.Type of POINTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground DPxessurized In-Ground QAt-Grade QMound>24 is of suitable soil DMound<24 in.of suitable sod <br /> DHolding Tank DOdwer Dispersal Component(explain) DPretreannart Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Desim Flom( ) Design iDesign Son Application Rate(gpdst) I Dispersal Area Required(A') I Dispersal Arca Proposed(st) ' System Elevation _ <br /> CDC) I ISao (Sob lcL-S - 1a;1.5 <br /> VL Tank Info Capacity in Total S of Manufacturer I <br /> Gallons (Gallons Units 3 <br /> ' J <br /> New Teas Etctina Tanks _a " .. <br /> I =U <br /> Septic or rg Tank 14 b I I�..S eo i t ! AA.Cc,ow-r- 12c I i ~ 1 r <br /> -Dosing Chamber I <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the PORTS shown on the attached plans- <br /> Plumber's Name(Print) Plumber's S' MP/MPRS Number I Business Phone Number <br /> Andrew W Meinholz <br /> ,414.• w- ' V 220165 I 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 ge444---4pproved ❑Disapproved I Sermit Fee Date Issued I =las' <br /> � syO�"- 9�—��sl <br /> 0 <br /> Owner Given Reason for Denial I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach In complete plans For the system and submit to the County may on papernat lea than 8 ir2 s 11 inches is sire <br /> SBD-6398(R.11/11) <br />