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1 <br /> _ . County 12 { <br /> Safety and Buildings Division Dane <br /> .`S _ ",t.,...7 Wr ffiW.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> rr PS e 5., ., Madison,WI 53707-7162 <br /> 13 - Alta -o015/ <br /> Sanitary E emit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis Adm.Code,submission of this form to the appropriate governmental tmit <br /> is required prior to obtaining a sanitary permit.Nona:Application - a to Project Address(if different than mailing address) <br /> the Department of Safety and Professional levies.Personal informed • "de dory <br /> purposes in accordance with the Privacy Law,s t S.04(1)(m),Stats. (p/y e 5 Co LA1ar( u W Y TT <br /> I.Application Information—Please Print AlI=nformadon s 20� <br /> Property Owner's Name Parcel <br /> B e..---n4 14 E LL Pa P Public Health MDC O9(2'• L841- 0 "4 5-o <br /> Property Owner=s Mailing Address Environmental Health Property Location <br /> Z 1 O 1-knectA e n Sr -e e T Govt Lot <br /> City,State Zip Code Phone Number a r <br /> 1Ap12Su/ALL W 1 5355 9 KF se.R /'�Section Z$ <br /> B.Type of Building(check all that apply' ^ Lot li T 9 N. R Z E <br /> ®Ior2Family Dwelling—Number of Bedrooms "} I Subdivision Name <br /> Block It <br /> DPubliclCommercial—Describe Use <br /> ❑City of <br /> QState Owned—Describe Use CSM Number ❑Village of <br /> ( 984 2 Town of YDIZ14 <br /> III.Type of Permit: (Cheek only one box on Lice A.Complete line 11 if applicable) <br /> A. ❑New System `Replacement System ❑Treatment/HoldinaTank Replacement Only ❑Other Modification to aisting System(explain) <br /> R. ❑Permit Renewal 0 Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> f Before Expiration Owner <br /> IV.((Type of POWTS Svstem/ComponeotlDevice: (Check all that apply) <br /> ®Non-Pressurized In-Ground 9PressurizecIn-Ground DAt-Grade ❑Mound>24 in.of suitable soil ❑Mound<34 in.of suitable soil <br /> ['Holding Tank ❑Outer Dispersal Coenponuti(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: 7 _ <br /> Design)F o(gpd) Design Soil Application Rate(gpdsf) i Dispersal Area Required(sf) Disposal Proposed(sf) System Elevation r <br /> [f /3'4>D v ' 93.0 <br /> VI.Tank Info Capacity in Total k of Manufacturer 2 _ <br /> Gallons Gallons Units ' <br /> New Tanis esistien Tads 2 e t a y -- <br /> /ZOO ��'/2.00 / au i7.:TA in + cG <br /> Septic nude(l%Tanl. ' --- ems M .. D£ X. 4 <br /> Dosing Clamber Sp 0 - I 800 / I <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 ✓ — GO r 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 /> roved ❑Disapproved PemtitFee Datelssued Issu', A• ‘.io• . <br /> s 6-6-20 /6 /w <br /> ❑Owner Given Reason for Denial Lad C j ■ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> o ) XFPTk 7 (K . - B— P.Pa/ ay 4$9/Yan'Y <br /> Mach AO cemptett oSons:err ttxaastm and submit to the County only ea none".not ica than 8 Mt a 11 incha in size <br /> SBD-6398(R.11/11) <br />