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_ County <br /> A Sarety and Buildings Division Dane ec% <br /> 3::- D., _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �, i'� Madison,WI 53707-7162 1 3 201 6 — x: 11 14 <br /> Sanitary Permit it Application State Transaction Number <br /> In accordance with SPS 38321(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 /> purposes in accordance with the Privacy law.,s 1 S.04(1)(m),Stats. �(AT1 D p L At�I <br /> I. Application Information-Please Prim.All information <br /> Property Owner's Name e/d rLA-r �e� Parcel* <br /> Da�l•raLD v "So/a.t■K.)e 'T I ERN Ey ( 8 u1(,. •ens 0 91 I - 303 - 6,42(d- 0 <br /> Property Owner's Mailing Address Property Location <br /> 105 S-TO lJ E 14 I LL 1.A.+4 V.. Govt.Lot <br /> City,State Zip Code Phone Number S e Via, S `/a, Section 0 <br /> Co T rArC1 , C-ta,o,,e. 1N( • -53 5 T 9 N, R it E <br /> II.Type of Building(check all that apply`` Lot# <br /> r-I CO Subdivision Name <br /> ®l or2 Family Dtvetling—Number of Bedroo ,s 5 l� <br /> `,� / Blocks Bp..LSTOL CIARt�EIJS <br /> DPublic/Commcrcial-Describe lsb►L �/ t -�' <br /> 0 City of <br /> OState Owned-Describe Use JUL 0 7 2016 CSM Number 0 village of <br /> Public Health MDC J &Town of a RI ST Q L <br /> III.Type of Permit: (Cheri:otErtiAMIllinefitalikteZattipiete line B if applicable) <br /> A <br /> gNety System 0 Replacement System DTreatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• 0 Permit Renewal 0 Permit Revision 0 Change of Plumber OPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ONon-Pressurized In-Ground OPressurizec In-Ground [IV-Grade OMound?24 in.ofsuitablesoil OMound<24 in.of suitable soil <br /> DHolding Tank DOthcr Dispersal Component(explain) DPretreatment Device(explain) <br /> V.Dispersal/Treatment Area'Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation , <br /> ri 50 . 7 /37s 1 /95o 7 1.7 <br /> VI.Tank Info Capacity in Total i of Manufacturer o <br /> Gallons Gallons Units 75 3 F <br /> u w <br /> o 'r 2, '' a G <br /> New Tanks Existing Tanks 2p. — is 0 -? <br /> 0 a V "r7:o, U. : <br /> Septic o►AeYhrgTank (.050 ll +© SQ9 <br /> , ,__ <br /> Dosing Chamber 8 o 0 J 1 Aon I LA C 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 ,A.----- /",J,. 220165 608-831-8103 <br /> Plumber's Address(Street,City State,Zip Colic) - --..._, <br /> 6813 County Highway K,Waunakee 1rV1 53597 �� <br /> ' <br /> VIII.County/Department Use Only .-` <br /> •.- <br /> 1 <br /> Approved ❑Disapproved Permit Fee ,Date Issued Ism' A t S' �` <br /> ❑Owner Given Reason forDenial <br /> '3)1," 741-20/6 < Aieij/kr 1 <br /> IX.Conditions of ApprovalTReasons for Disapproval <br /> S W_Low Sp'Xli So 1 L /��( �'G .Dl� 1�,( �f7 �oiv <br /> Mtatin to eomptan plan,lea thesstem and submit to the County only as panes not tenth=ti Iii x.11 inches in size <br /> SBD-6398(8.11/11) <br />