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i = - „RECEIVED County <br /> Saltety and Buildings Division Dane <br /> 11 s FEB 2 9 1016 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> p Madison,WI 53707-7162 <br /> - _ Public Health MDC <br /> (3-2 I —OQCr38 <br /> s Environmental Health <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 3S21(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 informatipn you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(IXm),Stets. tij r LO O M E uh;l'•,— <br /> I.Application Information-Please Print All Information <br /> ■ property Owner's Name Parcel S <br /> ;1 -E: L-1_.C. (C%0 ALFEAR-A D� l(,,tl goo,ES) - t- 0517Ob2 - 301 - Co(r5(o-o <br /> I Property Owner's Mailing Address Property Location <br /> Z935 S ASH 4ATCA-IEJ2y ROAD U+\1Ir 11'7 Govt.Lot <br /> City,State Zip Codc Phone Number r <br /> /. <br /> G.f'� V., i i r , Section 3a <br /> OVI D i se i vi l 53,711 <br /> T 9 N: R S E <br /> U.Type of Building(check all that apply) Lot s <br /> �1 or 2 Family Dwelling-Number of Bedrooms 4 ✓( 5ubbdaivision Name <br /> Block T <br /> c'''-CNER R`i WOO F)2£S r <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> lTown of M1DVLa;rorJ <br /> I <br /> III.Type of Permit: (Check only one box on line A. Compleke line B if applicable) <br /> A. 'New System ❑Replacement System ❑Treatme n/l'lold'mg Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Chance Of Plumber LJI•ernit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all ithat apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade QMound>24 in.of suitable soil 0Mound<24 in.of suitable soil <br /> ❑Holding Tank DOther Dispersal Component(explain) Orictu,abiieut Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispetsaliom Required(sf) ' Dis Area Proposed(sf) System Elevation <br /> G2 00 ', 2, / ' ' Se.r AT S i r'E <br /> VI.Tank Info Capacity in Total S of Manufacturer <br /> Gallons Gallons Units 7.., ^— <br /> Now Tanks Exerin_e Tanks - 3 - u <br /> _c3 is , w _U <br /> Septic or Holding Tank rash ?19L MEADe <br /> Dosing Chamber 6/50 V50 i t.A.E A o <br /> VII.Responsibility Statement-I,the undersigned,assume respdnssibility for installation of the POWS FS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz , 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) , <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> g/tpproved ❑Disapproved <br /> Permit Fee r Dan lssuldJ Jssu' °rnt Si .:• • /� <br /> {� D Owner Given Reason for Dcnial S/2 7K r lcc7 A_.‘ ' / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plats for the system and 9obmit to the County only on paper not less than 812e 11 inches in sae <br /> SBD-6398(R_11/I1) <br />