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County <br /> Safety and Buildings Division Dane ,— <br /> I ` S .. 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `, pS Madison,WI 53707- 162 <br /> % ,, , -, -ZOlo- Cam\ (Q3 <br /> Sanitary F en-nit 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 Servies. Personal information you provide may be used for secondary <br /> outposts in accordance with the Privacy Law,s.I S.04(1`,(m),Stars. FE- A L-rum (_ I E <br /> I. A••lication Information—Please Print All=nformation F! V <br /> `T rpeny Owner's Name P el# <br /> STEl/rN e BECKY �t SCi ot IDr , <br /> 08 - 32,4- 4061-0 <br /> Property Owner's Mailing Address Property Location <br /> 9 G2. 14 5 N-A-00W ,R t_,0 4,E T►2 4 t�- Govt.Lot <br /> City,State Zip Code Phone Number Lt/S VI vi,5 C y,,, Section 32 <br /> I� t t� 0(..M--1-01.1 I&J 1 535(o2. <br /> p <br /> D.Type of Building(ekesk all that apply) Lot# I <br /> T N; R 0 E <br /> aior2 Family Dwelling—Number ofBedrooms 4 ✓ 1 Su divisionName <br /> Block# 14t:A O J R,OA( • EST7fl S <br /> OPublic/Commcrcial—Describe Use <br /> ❑City of <br /> ['State Owned—Describe Use <br /> fast CSM Number ❑{Village of n <br /> Town of 1 t/L t o o Le-ro t <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> Ig New System ❑Replacement System O Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ['Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1V.Type of POWTS System/ComponentiDevice: (Check all that apply) <br /> EiNon-Pressurized In-Ground ❑Pressurizes In-Ground OAt Grade ❑Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> OHolding Tank ❑Other Dispersal Component(explain) OPretreatment Device(explain) <br /> V.DispersaUTreatmcnt Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) ( Dispersal Area Proposed(st) System Elevation <br /> �Cco0 • 4-i /_S�4 /s� .. 9�.6 3'y,4-/ <br /> VI.Tank Info Capacity in Total #of Manufacturer o o <br /> Gallons Gallons Units v <br /> Now Tanks Existing Tanis ` Q 0 2 .n <br /> C U v:H cn L t7 <br /> Septic or Holding Tank 1A.8/_ 11t;(� '. E I< <br /> Dosing Chamber `�P 1 t(i - —I ' 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 -,4__,____ Lt,� 220165 ( 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 , <br /> VIII.Coun /De artment Use Only <br /> P it Fee Date ed Issui :Age • titre <br /> proved ❑Disapproved tm _ -,,, <br /> �t. �❑Owner S � � i�-- r. j. <br /> IX.Conditions of Approval/Reasons for Disapproval I <br /> 1\on%to complete plum tar t esystens stud submit to the County only as popee not tart than 8 tit z 11 inches in size <br /> SI3D•6398(R.11/11) <br />