Laserfiche WebLink
c,,-;-.1-7,,,,, County l)I�'1 <br /> Safety and Buildings Division Dane <br /> `D S .7-. A,,d. N ru u ri Z01 W.Washington Ave.,P.O. Box 7162 Sanitary Permit Number(to be filled in by Co_) <br /> o,S Madison,WI 53707-7162 <br /> ' (3—apt(o O 0 l g 9 <br /> Sanitary Permit 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.15.04(1)(m),Stats. [3 Q4\U1 Li 120 A a <br /> I. Application Information-Please Print All Information ItJJ <br /> Property Owner's Name / # <br /> 50 a c�ss;✓t_ (do CcAsToi■-) CoKisitZUcT 0-0 ELI , ) orZo'7 - 0,74- 9 5.x..5- U <br /> Property Owner's Mailing Address Property Location <br /> .2-509 B‘RCA-k vvoorr 'Pass Govt Lot <br /> City,State Zip Code Phone Number <br /> S E , r Section r] <br /> VI, S f' IA <br /> CRuss Piiws kJ 531.- a <br /> T 7 N: R I E <br /> II.Type of Building(check all that apply) Lot ti <br /> Ell or2 Family Dwelling-Nun f ,4, - Subdivision Name <br /> W4130 Bloc:x 1—e-5 #r*I 0 BGvt Ai D-S <br /> ❑PublicfCommercial-Describe Use <br /> JUL ® 717 <br /> El <br /> of <br /> OState Owned-Describe Use CSM Number Village of + <br /> Public Health MDC ErTown of legs oss PLP t iJ S <br /> Environmental Hpalel <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. S3New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑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 /> I Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ['Pressurized In-Ground ❑At-Grade xiMound>24 in.of suitable soil OMound<24 in_of suitable soil <br /> ❑Holding Tank DOther Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: (��' / <br /> Design Flow(girl) (Design Soil Application Rate(ggpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation I✓Lb <br /> (Qua I I io� c I r r z a [ S AT S '— <br /> VI.Tank Info Capacity in Total 4 of Manufacturer 3 =7.: ta <br /> Gallons Gallons Units -2 e u <br /> New Tanlrs Existing Tanks e o . __ _ <br /> ^ G J f Sc -r, ■- v <br /> Sep¢ic or,goiding Tank l v'1-�S(.o �� i a O til I= Pc D <br /> t p � 1.-----A I � <br /> Dosing Chamber i _50 `� 66 v 1 M c 16 I <br /> VII.Responsibility Statement-I,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 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 /> Approved ❑Disapproved Permit Fee Date Issued Igcning A ent Si <br /> ❑Owner Given Reason for Denial (a-"I�Q / 5---2,2% C 40/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ego-(6_1 / ,,lApD x-f-fr ri (-- ,AiN(0 4/Q-ia-- 1-r !7 y -yvccliL <br /> r1, 91‘,.. f.s.fi, G°fl'ii,�-ri. �; f�/L c--x -r/rA00ye 14-A((2 P( frCL t.4.2 re4ficec <br /> Attach to complete plans for the system and submit to the County only on paper not less than 3 v2 a 11 inches in size <br /> SBD-6398(R.11/11) <br />