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RECFT\IFD <br /> ,„v:0, County <br /> Are' �r 1G16 Safety and Buildings Division Dane 61k- <br /> D S _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)• S Public Health MDC Madison,WI 53707-7162 <br /> 1%= - - Environmental Health I-3 -2t)1(4,- O{O(r,c <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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. TOW kf 44(.L ROAD <br /> I. Application Information—Please Print AU Information <br /> typerty Owner's Name Parcel# <br /> ANioIZEw 4c.cD JEI.iwA 0/6Dvrc-, docooi - lit - 9o8o- 0 <br /> Property Owner's Mailing Address Property Location <br /> 1 0 0 Sou-n-4 $ Govt.Lot <br /> City,State ii Zip Code Phone Number <br /> ��..�U N T l�� 5 �� v'S�J '/a> N.F r/a, Section 1 r7 <br /> E <br /> T Co N; R '1 <br /> II.Type of Building(check all that apply) Lot# <br /> I al ✓ 2 Subdivision Name or 2 Family Dwelling—Number sin w <br /> ' <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> APR. 0 1 2016 ❑City of <br /> ❑State Owned—Describe Use C.SM Number El Village of <br /> Politic Mealth MDC Y I 0 4/t Q Et Town of 5 PR 144.(,-1 DM-5. <br /> Environmental Health '1 [� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ®New System ❑Replacement System 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> r- <br /> � List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal El Permit Revision El Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> EjNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank 120ther Dispersal Component(explain) [`Z. cLO Vi ❑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 /> (A00 , 11 /,svo /Sao z rt,`v, 70,3/ 61,o / 6)77 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units U <br /> F.', U <br /> New Tanks Existing Tanks r 0 2; C 8 .°ra <br /> a U r , v7 u.t7 c. <br /> Septic or Holding Tank t ch V 1_ 102.¢10 M -T <br /> Dosing Chamber <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 `- .(.4—) . 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 /> Permit Fee Date Issued Issuin:Agent Sign. <br /> Approved ❑Disapproved $ ° / .00".. <br /> ❑Owner Given Reason for Denial -/ —�— <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> r--A �f — <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 la a 11 inches in size <br /> SBD-6398(R. 11/11) <br />