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,... ", County <br /> : Safe and Buildings Division Dane ( -1LA <br /> =`� - 201 W.W shington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> p Ma ison,WI 53707-7162 261 b-ONSH <br /> 1 <br /> Sanitary Fermit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this lnrm 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 /> uc oses in accordance with the Privacy Law,s.:S.04(1)(m),Stets. VLSM p r <br /> I. Application Information—Please Print All-nformation } - - <br /> Property Owner's Name Parcel 4 ■ <br /> 2_171 NO LI.C. CG/0 A-u �)€s w.j 4 tE.S") 0/08 - 301 - (040&9-o <br /> Property Owner's Mailing Address Property Location <br /> c2-,°) 35 S. r`lSPTC I.4EP`,4OArD/ ,t 2. T� Govt.Lot <br /> City,State Zip Code Phone Number 5 C, y 14E. /, Section .3 0 <br /> NA 140&Son) W 1 5 3 7 1 1 T 7 N; R V E <br /> II.Type of Building(check all that apply; /1_ Lot g <br /> Jlor2 Family Dwelling—Number ofBedrooms 4 9 Subdivision Name ,� y� <br /> Block 4 Ct WOO) f aC <br /> ['Public/Commercial—Describe Use <br /> ❑City of <br /> ['State Owned Use JUN-0 8 2016 CSM Number 0 Village of <br /> ®Town of M I,O (ice 173 Ai <br /> III.'Type of Permit: (Check on1yoR ..1 t J1 M'' . . Me line B if applicable) <br /> A. t <br /> KrNew System ❑Replacement System t♦Tree' <br /> re ttment/Holding Tank Replacement Only 0Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision El Change of Plumber ['Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1V.Type of POWTS Systcm!Component/evice: (Check all that apply) <br /> ['Non-Pressurized In-Ground QPressurizec fa-Ground QAt Grade gmound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑Holding Tank lather Dispersal Component(explain) ['Pretreatment Device(explain) <br /> V.DispersaUPreatment Area Information: <br /> Design/IFlow((gpd) Design Soil Applica'on nR�Rate(epdsf) Dispersal Area R uired(sf) D.pcpAl rap. ■yl f)_? System Elevation <br /> 6100 C�'r`� / a 1 I 4.--)re �/ S. Ii 5.E.,-r- 04' SLTE <br /> VI.Tank Info Capacity in <br /> Total 4 of 1 anu <br /> Gallons Gallons Units .0 2 e v ° <br /> N <br /> New Tanks Existing Tanks o = e d `' <br /> c.U et in rn cc.O <br /> Septie or Holding Tank 1 as,,r 9 I '� �1a A MEAD E <br /> )4 , .. <br /> Dosing Chamber 1 (9 5v6Y 1 tiS(/ i ` 4LarLT <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 I ._ 6%).-°.'.7-4----)/ 220165 606-831-8103 <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 ge <br /> kiproved ❑Disapproved <br /> ❑Owner Given Reason tbr Denial , 1)2 �l/%� <br /> S "1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Arisen 70 eOInpittt?Sam tar the System anti submit to the Count;only on paper oat less than 8 ttz:77 inches in size <br /> SBD-6398(R.11/11) <br />