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-_ :_�.::,.. RECEI\/ECG Cow <br /> ` Safety and Buildings Division Dane <br /> ' ` DEC _2 20b 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> $ Madison,Wi 53707 7162 <br /> Public Health MDC 10 6-- o b 36 2-- <br /> Environmental ea <br /> Sanitary Permit Application 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 marlin 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(I)(m),Stars. <br /> I. Application Information-Please Print All Information ©'E�.�'� L A <br /> Property Owner's Name Parcel <br /> pA-LAi. O(U Dc-ve-L FLA Eixr U.C. (tl6 AmeiA&ice e6— ) 09tH— 1 9 - 4523 - C3 <br /> Property Owner's Mailing Address P,urt.,ty Location <br /> 5 v 3$ c-,r- ssi-r,i i 0 TE(Z, GE. Govt Lot <br /> City,State i ,' ' Zip Code Phone Number r- r <br /> P\i4 Q s i-j I�l.,L W I 5 5 51t1t% /� A_ Section ( <br /> IL Type of Building(check all that apply) Lot 4 T 9 N: R t E <br /> NI or 2 Family Dwelling-Number of Bedrooms i ��� divt <br /> 3 Subsiom Name <br /> - Block= I-611 ^I J ppti1 f <br /> El Public/Commercial-Describe Use <br /> D City of <br /> OState Owned-Describe Use CSM Number <br /> I D village of <br /> OTown of V g,,t s-I-D L. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> IA" fNew System D Replacement System ❑Treatment/Holding Tank Replacement Only 1[]Other Modification to Existing System(explain) II <br /> a D Permit Renewal 111 Permit Revision D Chance of Plumber DPermit Transfer to New List Previous PermitNtattber and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Cheek all that apply) <br /> ONon-Pressurized In-Ground DPressurized(n-Ground DAt-Grade pvlound>_24 in of suitable soil DMourd<24 in.of suitable soil <br /> 0 Holding Tank DOther Dispersal Component(explain) DPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: System Design Flow(gpd) Design Soil Application Rate(gpdssf) Dispersal Area Required(st) Dispersal Area Proposed(d) <br /> C.;00 , ( / OC) U Zoo Se.i/.1►-1 SITF <br /> VI_Tank Info Capacity in Total 4 of Manufacturer z, c- <br /> Gallons Gallons Units =_ o o ts <br /> New Tank S ---- 1E5'igingtanks - 3 _ _ _ <br /> U it w a v <br /> Septic oaiirarding Tank i '.9.CJ I " ,t s-6 . k/• Iva e I 7‹ <br /> Dosing Chamber &5 o _ lei Q _EFk_1)±:, X I <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 1 MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz ,4 (,v,; "")-1 .-1 220165 608-831-8103 <br /> MrPlumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> Viii.County/Department Use Only <br /> P it Fee, Issued Issuing eat <br /> Approved ❑Disapproved S J � /n, <br /> ❑Owner Given Ran for Denial / /4 ' 12—1 � 7Ir( ,�; _ <br /> IX.Conditions of Approval/Reasons for Disapproval �� �� j-�i��F <br /> PRo * 1r ,pow„ f rz'oi rc7F- AAp l <br /> rAoA c*IL CVAya*-ti r, s-°IG Ey-ch-i�"l1' �o Y F 74.4.x, cci <br /> l Attach to complete plans for the system and submit to the County only on paper not less than 8 r2 x 11 inches in size <br /> S)3D-6398(R.11/i)) <br />