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County ;\--,• Safety and Buildings Division Dane <br /> y.` s _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> -\ ps Madison,WI 53707-7162 <br /> -. , --- \3-- Zc: t3- eOD -( <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. E.- &Li 5 Ul 0 A-(s j eCLt✓J,(_ <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 'Uig, Vi4 lkii,A-DISv LLC 0700 2.03 L11-30 —0 <br /> Property Owner's Mailing Address Property Location <br /> Li: U( S +.. `+ ( O ii.v c D .t V E_. Govt.Lot <br /> City,State Zip Code ' Phone Number t <br /> 1v\ �r 1�1 5c.-ii. ■fl.� ( S 7j 7 1 z 5 bl•./ /4, �11t/ /4, Section Z.-t;' <br /> T '7 N; R 3 E <br /> D.Type of Building(check all that apply) Lot# <br /> ®I or 2 Family Dwelling-Number of Bedrooms O Subdivision Name <br /> ❑Public/Commercial- n <br /> EC E I V Block# S(tZuC,, 1- iij <br /> ❑City of <br /> APR 2 8 2016 CSM Number ❑Village of <br /> ['State Owned-Describe Use N Town of NI, 4O9I„A-7.7 '), \ <br /> Public Health MDC <br /> HI.Type of Permit: (&Vct-(figli-Wii--glAttMcattA. Complete line B if applicable) <br /> A. 4 " ❑Replacement System VTreatment/Holding Tank 4tc$lasem i4.9rtly- Other Modification t.Existing System(expi.n) <br /> B. Permit Renewal —Permit Revision List Previous Permit Number and D e Issued <br /> C Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner (.b0 3 i ci/ 3v) 0 j <br /> IV.Type of POWTS System/Component/Device: (Check all that aPply) S-A -A7- `17-5.5—s <br /> ❑Non-Pressurized In-Ground Pressurized In-Ground DAt-Grade Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑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 /> 1s 0I (,C7 '--15U '13L., `x'7. 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer L <br /> Gallons Gallons Units ti <br /> c ^ U v V <br /> New Tanks Existing Tanks ` -p Y C '',,, ,o c <br /> G U v: rn [_ C7 <br /> Septic or midi+ Tank 1,t45o �' I�SU ( "i�A-1)t-' <br /> Dosing Chamber a 0 J "-_ 500 I <br /> 14 F,sI'I?G 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 ....._ .C-..›. 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee W1 53597 ---" ^--- � <br /> VIII.Connty/Department Use Only / <br /> proved ❑ Disapproved Petmtt Fee I Date Issued I umg Agent Signs re g-ete-s— <br /> �_ i2i6 . <br /> ❑Owner Given Reason for Denial _ a <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> TW's 4/,rc— 7 A J --° CoN/Y ' l� ,NIa(/‘isA ?)MA117 Ego r7-4-li'' ' <br /> 1-1,01 !4S Alf Lc-0( �",<.-7, (}-,4 "u4!), (0, C. — 2 5' <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 inches in size <br /> . tracb co <br /> P P <br /> SBD-6398(R. 11/1l) <br /> • <br />