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i i vy\'''' s RECETV-ED _�_� County Safety and Buildings Division Dane ;1' DS 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) . ,\ ps • NOV 10 2015 Madison,WI 53707-7162 ";..... . Public Health MDC Lnytpon t tits fi a State Transaction Number elna.r rezmt Application In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 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) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04(1)(m),Stilts. j l I-_V E-12.--.6 E L(-, (ZOAD L Application Information-Please Print All Information Property Owner's Name Parcel# M(IZIaC UN MA0150 LrLC Ur/ 0b.- 2705- C00'7&-O Property Owner's Mailing Address Property Location CO b 0 1 SO LA 1 t-I TO In/N E C)K 1 V L.- Govt.Lot City,State Zip Code Phone Number G y f5 id 1/4 Section 2(i 1I\Ac 01 SCriN stki l 53'7 13 T 17 N; R E II.Type of Building(check all that apply) Lot if R1 or Family Dwelling-Number of Bedrooms 5 Name j ` / Block# — S Z.. t.L. �t'C%(.A....01,LV ❑Public/Commercial-Describe Use ❑City of CSM Number ❑Village of ❑State Owned-Describe Use ®Tomof lI l D0l_c�T-r1t"J III.Type of Permit: (Check only one box on fine A. Complete line B if applicable) I New System ❑ A. Replacement System OTreatment/Holding Tank Replacement Only QOther Modification to Existing System(explain) 13. Li Permit Renewal ❑Permit Revision ❑Change of Plumber QPcrmit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV.Type of POWTS System/Component/Device: (Check all that apply) RNon-Pressurized In-Ground ❑Pressurized In-Ground at-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable sail 0 Holding Tank Either Dispersal Component(explain) LlPretreatmentDevice(explain) V.Dispersal/Treatment Area Information: _ Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sl) ' System Elevation VI.Tank Info Capacity in Total it of Manufacturer Gallons Gallons Units as o u u New Tanks Existing Tanks . o , E b m 9 _ m a.c) in vt to i.Q o. f Septic ae41e 6iegTank _ _I /[e_ tQ�./5� y kite L`.l 0I"' �X/• I DosiagCllmubcr t V4/'Q0 11410 . i4 YMWALIF 17C, . VII,Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans, Plumber's Name(Print) n Plumber's Signature MPIMPRS Number Business Phone Number At`40 a-E'W. Cu U I y�f t.tZ t ni,y- -(-r A)1.- -,r A.D.-0 1 (>3j 608-831-8103 Plumber's Address(Street,City,State,Zip Code) 6813 County Highway K,Waunakee WI 53597 VIII.County/Department Use Only Approved ❑Disapproved Permit! /F�ee ,r Date Issued issuing nt Si tut ❑Owner Given Reason for Denial $47✓1 i'^I 23 fr iX.Conditions of Approval/Reasons for Disapproval Attach to complete plans for the system sad submit to the County only on paper not len than 8 IR x11 inches in size '!�S=-W.":s`kneL'M3_a?t+x5*.W4:::..art1..haw.l.:,':_:.:iaiyn.iti-»na' -x,.n «.ti::a._-.nr..u:,:-,..,`i.+Mir-. -.tr.N..�,...:e:.:'ei+!'Nww.W.:wax xe�+.;tt;..:.�.�.-.fix,-:v+.tix,.v:N-,��-xsv a.w-.:•:,tii�...w,4�o>•w.4,w3.M1..�.wY..+..we...x...+v..d,:..:rxk'D» SBD-6398(R.11/11)