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F-6G 7 z..2,7 P f l !qs-i County PI Safety and Buildings Division Dane .z�, D S _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be tilled in by Co.) P Madison,WI 53707-7162 Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 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) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes m accordance with the Privacy Law,s.15.64(1 gm),Stets. G S Lei LAN/E.- I.Application Information-Please Print All Information Property Owner's Name G/O AM BICtAI(.E Parcel g 1 'PAuLsoN D€Vr✓I-OPM,E J-r LC.0 �I' •Nona&S INC. 09(I- 174- 4554e- G Property Owner's Mailing Address Property Location 5E5 33 KA S S LA t•( 0 1 e-12.12-4 cE Govt.Lot City,State Phone Number y MAr�s►+A �� 535 9 Z-- \1./ 'V, S� '/.,Section 1 / T 9 N: R II E 1Q.Type of Building(check all that ply) /, Lo# 21 or 2 Family Dwelling-Number o '1 L--"----(1)' r' ( (Subdivision Name _ ., T`;P� ock# r-"LERMAN`S 400mon) ❑Public/Commcrcial-Describe Use '� ['City of MAR 1.$ 1016 CSM Number ❑Village of ['State Owned-Descnbe Use t� Puc',.rie;Lh ND.0 !_r'ITown of 8 V L 3-r6 L Fnvironm nt I}4 Ifi.Type of Permit: (Check only one box on line A. Cot I3 to line B if applicable) A. Ey New System ❑Replacement System ❑Treatnient/Holding Tank Replacement Only [Daher Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision ['Change of Plumber I❑Permit Transfer to New List Previous Permit Number and Date Issued IV.Type of POWTS System/Component/Device: Check a J Owner Before Expiration YPe ( ^' I tha a 1r; 7 ❑Non-Pressurized^In-Ground ['Pressurized In-Ground DAt .• ound?24 in.ofsuitab, •ilk. ur24.<24 fsfidia e it ❑Holding Tank [JOther Dispersal Component(explain) IN• ent Deffee(nl plain) r-- ..-- V.Dispersal/Treatment Area Information: `- Design Flow(gpd) Design Soil A/p/plication Rate(gpdsf) D. •ersal Area Required(sf) Dispersal Area Proposed(st) I System Elevation EC on Lo GO •,O J I t.% ;Z J Si-fE VI.Tank Info Capacity in Total #of ll Manufacturer Y. Gallons 1 Gallons Units V°°u Y New Tanks Existing Tanks ' c :? ? II 11 a a /II��QQ e.V U m in u.V Sept gitltmtrtyTank l aCGJ 1.156 °2 M E-A-D v >< . Dosing Chamber I 6 5o ----- caSO I 'M,£a D _ X VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/WIPRS Number Business Phone Number Andrew W Meinholz ._"4.....--c_ /...5." + 220165 608-831-8103 Plumber's Address(Street,City,State,Zip Code) V 6813 County Highway K,Waunakee WI 53597 VIII-County/Department Use Only ,,,,,,(( Permit Fee. Date ksued Issui Age Si e grApproved ❑Disapproved p,r' (� 7��r�/ AIM/41m- IX. ❑Owner Given Reason for Denial $/ i/ / r r 72-r b ( 1 Conditions of Approval/Reasons for Disapproval �� Y"""') PI�Eci ihoc4,o P4'76.. J(?C I4 4 /c I-6'7 So!G- Com.9,4c-la1,' 1`- ft I C�J ,9Yr A'I) PC CG4L,0.. Fi -(c r Attach to complete plats for the system ao l submit to the County only on paper not less than 3 In 111 inches in sine SBD-6398(R.11/11)