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�■aMryi•my County <br /> --a.i ... Safety and Buildings Division Dane <br /> ' 0 S P `�� 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,Wi 63707-7162 (3-2O3Sz <br /> i,rirr,.��: <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the .pro'slate:o en.1 ,it _ <br /> is required prior to obtaining a sanitary permit. Note:Application forms for:a' s. ;, "e"e ` Project Address(if different than mailing address) <br /> t h e Department o f S a f e t y and Professional Servies. Personal i n f o r m a t i o n yo , .. s - <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stets, BAY Li 2re,'. LAINE <br /> I. Application Information-Please Print All Information OCT 21 2015 _ <br /> Property Owner's Name Parcel f <br /> M'iz 04 mAroi5oKi LLC Public Health MDC 0'700 -10 -4t LOT6 <br /> Property Owner's Mailing Address Environmental Health property Location <br /> (aDCM Scum TOWN+ DIZljG* GOY.Lot <br /> City,State 'n! Zip Cade Phone Number cF %, Sky t/4, Section 2.6 <br /> kill IVO VV n '',5'3 T I/ N; R 6 E <br /> IL Type of Building(check all that apply) Lot/ <br /> 56 or 2 Family Dwelling-Number of Bedrooms J 3ubiaivision Name <br /> Block 4 <br /> �[- 'Public/Commercial-Describe Use ❑City of <br /> DStete Owned-Describe Use CSM Number El V Village of d <br /> (2Townof NAi ODL�TOoV 1 <br /> IIT.Type of Permit: (Check only one box on line A. Complete line 0 if applicable) <br /> A' g New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only (explain) <br /> []Other Modification to Existi ng System <br /> B. ❑Permit Renewal ❑Permit Revision [DChane of Plumber OPermit Transtbr to New List Previous Permit Number and Date Issued <br /> Betbre Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Cheek all that ap,lyL___ <br /> lbll....0 OPressurized In-Ground ❑At-Orad.`"/Mound 24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Son Application Rate(gpdst) ( Dispersal Area Required(sg Dispersal Area Proposed(st) System Elevation <br /> rl GO _ .. .t� l /ZS u I / 75- 1 sc-4--es,VI.Tank Info Capacity in Total P of Manutheturer <br /> Gallons Gallons Units <br /> .n _ <br /> New Tanks Existing Tanks .I S 1 <br /> aU 0 oe i.E5 a. <br /> Bootie Wield%Tank 14150 --- ` pso a'], �, V iG <br /> Dosing Mamba 500 "... ®v I _ µ*-i-0 <br /> VU.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTE shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature I MP/MPRS Number Business Phone Number <br /> Andrew W M nholz .--Gt,l., 220165 , 608-831-8103 <br /> Plumber's Address(Sheet,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII Eounty/Departtnent Use Only <br /> 1�°1,/Approved ❑Disapproved Permit Fen JDate Issued Inuit) rot <br /> ❑Owner Given Reason for Denial _ s/1 WP r 494 3�'1 C <br /> 11X.Conditions of Approval/Reasons for Dis approva, /� ? h.7�'or.f�,eicaz Aeo c.7"MOwY. .r(r .- <br /> . <br /> fr, fwe. cohe4C " /-0/4 Sy,c/q- -1,-*: 4/140 /(het/cc4f logic, <br /> Attach to complete piens for the system end submit to the County only on paper Notices then 8 in x 11 inches in site <br /> SOD-6398(R.11/11) <br />