Laserfiche WebLink
••.-1-1-,∎.'.• County <br /> Safety and Buildings Division Dane <br /> ;``D S = 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P S .7: Madison,WI 53707-7162 \3-2eito---c9 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(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 Settles. Personal information you provide may be used for secondary *� <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. `14 CAN)0 Eit. WOOD 1 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name _ 4 <br /> Dw�nr� U? EA R . =( , �" ' - <br /> Property Owner's Mailing Address n Property Location <br /> 4 V o g A 4 o 1 R\J 00 U R O A C) Govt.Lot <br /> City,State Zip Code Phone Number , , <br /> OYLC.GzON VJ l � •Z�t �-'''S�J /> J`4 E �, Section �- <br /> Try N; R 1 0 E <br /> II.Type of Building(check all that apply) /� Lot# <br /> Ri1 or 2 Family Dwelling-Number of Bedrooms 1 ''`c 1 Subdivision Name <br /> Block II (---' O L" ST0KLE ' . -ri TE S <br /> OPublic/Commercial-Describe Use <br /> ❑City of <br /> ['State Owned-Describe Use CSM Number ❑Village of <br /> APR 2 7 2016 ®Town of R LA LA t i,i) <br /> TH.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Pt,bkc Health MD <br /> LNI New System O Replq¢ 11ta nt/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. O Permit Renewal O Permit Revision ❑Change of Plumber ['Permit Transfer to slew List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1V.Type of POWTS System/Component/Device: (Check all that apply) <br /> El Non-Pressurized In-Ground ❑Pressurized In-Ground []At-Grade , Mound?24 in.ooff suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank Other Dispersal Component(explain) OPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(_spdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> (e00 _ ='',6 2.--- /or~ l oe, S er A-- S ti <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units E c 7. o <br /> New Tanks Existing Tanks - •v 0 C u . a rs <br /> e..U rr a to r_ O a.. <br /> • <br /> Septic or Holding Tank I..X0 CI tat(' .,4 t o e .x- <br /> Dosing Chamber G5O 0 , MM GAotS. x <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 1/U - 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 ,-,. I <br /> Approved ❑Disapproved P it Fee ,/� �Daate Issued,/ Issuing Agent Si ar. �. V <br /> ❑Owner Given Reason for Denial . <br /> IX.Conditions of Approval/Reasons for Disapproval /' <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in z 11 inches in size <br /> SBD-6398(R. 11/11) <br />