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r <br /> 61g 7 2-cx,7 fowl-0- 11 7g5j <br /> ra „ County <br /> Safety and Buildings Division Dane <br /> 13S 201 W.WPermit Washington Ave.,P.O.Box 7162 Sanitary P Number(to be filled in by Co.) <br /> rb. : PS Madison,WI 53707-7162 <br /> • <br /> Sanitary Permit Application StateTnmmction Number <br /> In accordance with SPS 383 21(2),Wis.Mm.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.151)4(1)(m),Slats. 0 S 1■0 LA N E <br /> L Application Information-Please Print All Information ' <br /> Property Owner's Name C-10 AM B IL5I C Parcel PAUL-501•1 DtvrLOVNVEAJr LIC <br /> -Nolaas IN 09(I- !94- 4551,- G <br /> Property Owner's Mailing Address Location <br /> 5E56- C-12A S S LA k( D 1_E2'A C E Govt Lot <br /> City,State ,/ Zip Code Phone Number 19 <br /> MACc.SN-A Lt- (i II 5355 9 9 '�, S� '�,Section <br /> J T 9 N; R H E <br /> IL Type of Building(check all that apply) /, Lot g <br /> WI or2 Family Dwelling-Number o ms Subdivision Name <br /> (� T°� 931 <br /> Block it - LEI-4MA-NIS 4001:n04 <br /> ❑PublicfCommcrcial-Describe Use <br /> 0 City of <br /> KAP r, 9 616 <br /> ❑State Owned-Describe Use CSM Number t❑�V Village o[ <br /> Put''.-+e:a:h fr'' gTownof 7j 1Z 1,5TY)L <br /> Environme7 1y.�ea <br /> TR.Type of Permit: (Check only one box on line`. Com line B if applicable) <br /> A. {�p� <br /> New System ❑Replacement System 0Trtxhnent/1-lolding Tank Replacement Only ❑OTher Modification to Existing System(explain) <br /> B. [Permit Renewal [Permit Revision [Change of Plumber [Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) . <br /> ❑Non-Pressurized In-Ground )Pressurized la-Ground 0At-Grade DMound>24 in_of suitab;esoil pilound<24 in.of suitable soil <br /> ❑holding Tank DO her Dispersal Component(explain) ❑Pretre rMment Device(explain) <br /> V.DispersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Ap lication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 62 00 /b� v f2 ov Serf A�'r St-t7E <br /> VI.Tank Info Capacity in Total d of Manufacturer <br /> Gallons Gallons Units u is v 2 <br /> New Tanks Existing Tanks 2 3 - - er e c <br /> It //� ��tn��/ ,I c-V v:; in a.O _ <br /> Septic a&Mi g Tart. l d8 to I,AS6 °Z M E.AD X <br /> Dosing Chamber (a 50 f U55 I • E A-Q F x <br /> VII.Responsibility Statement-I,the undersigned,assume respoasrbnTrty for installation of the POWTS shown an the attacked plans. <br /> Plumber's Name(Print) Plumber's Signatur_ MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz ,.mac_ C...S 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 Usc Only 1 Q Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature S <br /> 0 Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and err brnit to the Conroy only on paper net less than a tO x 11 ienbrs in size <br /> SBD-6398(R.11/11) <br />