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County <br /> 5-- Safety and Buildings Division Dane <br /> . .. <br /> .,... <br /> • z : D , 201 W.Washington Ave.,P.O.Box 7162 sanitary Permit Number(to be fillal in by Co.) <br /> Madison,WI 53707-7162 <br /> ... <br /> 1 ....i ,f_--Li t;sc.) L.3(....... ...,....>/- <br /> .._.... <br /> Nuntber <br /> State <br /> Sanitary Permit Application Transaction <br /> In accordance with SPS 38321(2),Wis.Mm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Now 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(0(m),Stars. 6 R.ASS LA N't D TE. ACE <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel 0 <br /> k 5-V 1 KI A NA) S7-E P I-4/4 NI(e V.1.-E-04 Ni EK . <br /> Property Owner's Mailing Address Property Location <br /> 994 Li-l-Art0L.E-1 LAN Govt.Lot <br /> City,State Zip Code Phone Number <br /> s■ki lit C,1d%,Section i 1 <br /> &ALI PKA/K i E. 40 I ...,- 5 y 0 <br /> T N: R i 1 E <br /> II.Type of Building(check all that apply), Lot S <br /> Efl or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block;I <br /> OPublicoConunercial-Describe Use <br /> 0 City of <br /> CSM Number El Village of <br /> OState Owned-Describe Use <br /> I Li I (.02 El Town of S Lt NI P 12-Ar t re..,t'E.-- <br /> rn.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A- Ki New System 0 Replacement System I:Treatment/Holding Tank Replacement Only DOther Modification to Existing System(explain) <br /> B. D Permit Renewal El Permit Revision 0 of Plumber DP.*Transfer to New List Previous Permit Number'and Dale Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground OPressurized In-Ground I:At-Grade OhAotmd>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank DOther Dispersal Component(explain) pPretreatment Device(explain) <br /> V.DispersaVTreatment Area Information: <br /> Design Flow(grid) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) ' Dispersal Arca Proposed(at) System Elevation , • <br /> ta200 • ../ /S ).? /3-/2- 9..4 3' 3.3 ,).J <br /> VI.Tank Info Capacity in Total N of 1 Manufacturer <br /> Gallons Gallons Units <br /> :gr., rig 1.t <br /> New Tanks Existing Tanks Ta" ,..." 2. 'el -0-:-.. .:... <br /> Septic oettoidiag Tank I2 Pi& — ,101 (a. '=2- <br /> Dosing Chamber Chamber ......., <br /> (0C;a0 tieS <br /> VU.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 f MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz .......4.-4- t ---/--...-,.- 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> vin.County/Department Use Only <br /> Permit Fee ate Issued ISSAre <br /> pproved 0 Disapproved <br /> 0 Owner en Giv R for Denial _ - D - r <br /> . _ . 2-12 .22/6 C <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> (3) 6'it- Of' cGGS:-- /S72 S-Q, fl% <br /> Attain to complete plain for the system and submit to the County only on paper not less tbau 8 la a 11 inches in we <br /> SBD-6398(R 11/11) <br />