|
County
<br /> Safety and Buildings Division Dane OA.
<br /> D S 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)
<br /> P
<br /> $ Madison,WI 53707-7162
<br /> t;::,. I -2015 - 1)3
<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 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. 15.04(1)(m),Stats.
<br /> I. Application Information—Please Print All Information G LO S 1-7-1,-6-t E ROA-o
<br /> Property Owner's Name Parcel#
<br /> -O bNA EIS Po OLt la 1 rzc ops ( Ki( 0 5 1 0 3 52 - 9 55 5 -0
<br /> Property Owner's Mailing Address _ Property Location
<br /> (0 M/- 1 N. Sl —Et l Govt.Lot
<br /> City,State ( , r \n Zip Code Phone Number
<br /> TA L M K MA 0 Z i7 U (;t S t/a, Mid '/a, Section 3
<br /> II.Type of Building(check all that apply)1 Lot# T 5 N; R (0 E
<br /> gIor2 Family Dwelling—Number ofBedroo 1 2- Subdivision Name
<br /> �I! I/ Block#
<br /> ['Public/Commercial—Describe
<br /> ['City of
<br /> ❑State Owned—Describe Use NOV 1 7 2015 CSM Number ❑Village of
<br /> Public Health MDC
<br /> III.Type of Permit: (Check
<br /> 5e2_9 �fownof lCr'L N-i b
<br /> celivrisilfimedinieffeApinplete line B if applicable)
<br /> A.
<br /> ONew System 0 Replacement System 0Treatment/Holding Tank Replacement Only ['Other Modification to Existing System(explain)
<br /> B. ['Permit Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued
<br /> QPetnlit Transfer to New
<br /> Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that appl
<br /> ❑Non-Pressurized In-Ground ['Pressurized In-Ground at-Grade 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 Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation
<br /> Le U0 t/ , G Jan © I . - 72. 7 I .C:7-1-c_.
<br /> VI.Tank Info Capacity in Total #of Manufacturer - —
<br /> Gallons Gallons Units ,. >
<br /> P o
<br /> New Tanks Existing Tanks 2 U
<br /> ti
<br /> Y, U jg y el' .p. 8. g
<br /> Septic or-Licking Tank t i 20 O UDC) kit EA K.
<br /> Dosing Chamber So 0 ��
<br /> So 000 1 l•-'1'rt=,ADF- �!
<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 MP/MPRS Number Business Phone Number
<br /> Andrew W Meinholz Y (A.) . -)--2----z 220165
<br /> 608-831-8103
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 6813 County Highway K,Waunakee WI 53597
<br /> VIII.Conn ty/De partment Use Only _
<br /> Approved ❑Disapproved Permit Fee Date Issued Issuing A. .i• lure
<br /> ❑Owner Given Reason for Denial $I l 2.46. 11,20-2,1 / C A /
<br /> IX.Conditions of Approval/Reasons for Disapproval J
<br /> P,91Eq' /ttowv. ' ,ray(--,,, (' 7-(...- AN, /k4 f E t ,poG,,,'rGo,,,'
<br /> mow4 so/G czi,e y�,,-Ti .r.��G ey,,i, ate, 1/ -1Vc.;4, 4 T &
<br /> E' h, Z`�-, '1` .3,, jj 0I c `. (f , 4
<br /> ' Attach to clmplete plant for the system and submit to the County only on paper not less than 8 in x 11 inches in size
<br /> SBD-6398(R. 11/11)
<br />
|