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• <br /> ,n:=f= County <br /> Safety and Buildings Division Dane <br /> z': iI • _ 201 W.Washington Ave., 'K4r�E it Number(to be filled in by Co.) <br /> ., n Madison,WI 5370 <br /> ..� . <br /> ... . ``� DEC t9 �7 -201 5-UQ 3 <br /> Sanitary Permit Application State Transaction Number <br /> Public Health MDC <br /> In accordance with SPS 35311(2),Ems Adm.Code submission of this form to the appropriately". �yi f h Health <br /> is required prior to obtaining a sanitary permit. Note Application forms for state-owned POW''[[''SS'are su minted to Project Address or 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.I5.O4(1Xm),Slats. (ATLA40- u aH -r0 lant `(mac kD <br /> I. Application Information-Please Print All information <br /> Property Owner's Name ` Parcel'i <br /> ivtM2. t< DokiN A \IoiZBurz (dO N411'011116 CoNI' AIS 0 t IV- 344 935a - <br /> Property Owner's Mailing Address Property Location <br /> 311-i 5 CA , D E t 4 LANE Govt.Lot <br /> City,State f Zip Code Phone Number <br /> t 34 <br /> SuN Pn.A,l KIE: 141 5 • Q S kl SE t:, Section <br /> II.Type of Building(check all that apply) '''• Lot= !I T R I E <br /> ®1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> CSM Number ❑Village of <br /> QState Owned-Describe Use <br /> 05 94 5 LXl�y Town of I)U.14 KI <br /> III.Type of Permit: (Check only one box on line A. Complete line B if npp lienble) <br /> A. ❑Mew System '0 Replacement System I❑Treatment/Flolding Tank Replacement Only IOthcr Modification to Existing System(explain) <br /> R eco 14 hl FELT <br /> List Previous PermitNumber and Date Issued <br /> I fPermit Transfer to New <br /> B. ❑Permit Renewal ❑Permit Revision 10Chanse of Plumber `/� v to-�'Z�Z <br /> Before Expiration i Owner / T O <br /> IV.Type of POWTS System/Component/Device: (Cheek all that apply) 1.Ohrjf-toicit7 DA WE tp2 - to 701 <br /> ❑Non-Pressurized In-Ground QPressurized fn-Ground Rim-Grade QMound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> Hoidins Tank DDther Dispersal Component(explain) OPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) ' Design Soil Application Rate(gpdst) ' Dispersal Area Required(st) ` Dispersal Area Proposed(sf) l System Elevation - <br /> t 1 _ f <br /> VI.Tank Info Capacity in Total 3 of Manufacturer <br /> Gallons Gallons Units <br /> ..V =) <br /> "New Tanks ( Ecistine Tanks I J^—, 3 <br /> Septic o,-Iierdtaa Tank 1 —^ I 10 0 0 1 000 1 1 M C/r1 P K 1 i I I i <br /> Dosing Chamber I — i Lai 0 000 Q0 I I t / 1)t! I t/ <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz Iiti_ - 220165 608-831-8103 <br /> Plumber's Address(Street,City,Slate,Zip Code) l. <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only .-- f <br /> Approved ❑Disapproved <br /> Permit Fee Date issued <br /> 201.51 icstti As Sia lure /41a4P-- f <br /> ❑Owner Given Rtwun for Denial 50257/"-T~ 12-10 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ti-aliftr- 4-r- G-Rme pw7f . >trrTof -�s <br /> I "fit 7 0' 7- /e --crify/rrcr 'Y4- Y' -'1 - <br /> - I <br /> Attach to complete plans For the system and submit to the County only on paper not less than S in z 11 inches in size <br /> SBD-6398(R.11/11) <br />