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„,::_.-° County <br /> :fl . SCANN 'W P.O. 7162 Dane o.) <br /> Sanitary Permit Number(an a soled m by Co.) <br /> '-.S P S Madison,VVI 53707-7162 <br /> ”' /3 —,,?fri( —Go,zos) <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38331(2),Wis.Adm.Code,submission of this form to the appropriate govmunental wit <br /> D required prior to obtaining a sanitary permit.Note Application forms for state-owned POWTS arc sobmined to Project Address(if different than mailing address)— <br /> the Department of Safety and Professional Berries Personal information you provide maybe used for secondary �7 <br /> rann�in uwsith the Privacy Law.s.S c 4(;xm),Soo ?Kt(461 NOSE RoAO <br /> L Application information-Please Prina Al Information Lai eaH lelttaWUOJ!n�a <br /> sName DGW 43Iea 4�!IGrcd Parcel DILLIS ��08- 313- 9210-o <br /> Property Owner's Mailing Adams MI o g lnr Propene Location <br /> "502 EAST PASS a� �� Govt Lot <br /> City,State Zip Code <br /> MAD130N4 w{ 9 W %, 4Scetion 31 <br /> II.Type of Bolding(cheek all that apply, 4. Lot: <br /> T (o N: R 9i E <br /> [l�ior2Family Dwelling-Number of Bedrooms ('T ) 2 Subdivision Name <br /> /l Block S <br /> QPubliccComoxrcial-Describe Use <br /> 0 City of <br /> QState Owed-Describe Use CSM N �` 0 Village of <br /> (2$6I IR Town of VEtZONIA <br /> SA.Type of Perm(Check only one boa on fine A.Complete Woe 13 if applicable) <br /> AiVONew System 0 Replacemera System QTreemuent/Holding Tank <br /> Changc TactRepiacanent Only QOther Modification to Existing System(explan) <br /> B 0 Permit Renewal 0 Permit Revisiot Qof Plumber Plumber t <br /> Transfer to New list Previous Permit Number and Dam Issued <br /> Before Expiration Owner <br /> IV.Type of PONS System/Commonest/Device (Cheek:ill that apply) <br /> QNon-Pressurized -C-roved QRemaize In-Ground 0At-Grade QMowd>24 in.ofsuitablesoil Q Mound<24 in.of suitable soil <br /> QHolding Tank OC her Dispersal Co noco tt(explain) Oftetntatment Device(explain) <br /> V.DiisspersaVTmtment Area Information: <br /> Design Flow(gpd) 4., ionRne(gpdsf) 1 Dispersal <br /> Ana Remd(sf) 1 Disposal Area Proposed(sf) System Elevation <br /> i (!00 <br /> civ,;>c 1. /94,),S-- 1 SEr a r ScrF" <br /> VI.Tank Info Capacity in Total N of Manufacturer - z <br /> Gallons Gallons Units -o 2 „ <br /> New Tanks 'Easing Talcs 2 c -if S 42.5 1 <br /> / .sp/ - 1 <br /> a.Lt a:w en c0 <br /> Sepue«Holding Tank ( 2�JY I I0$(a .a. ME�Ir(o� I ` <br /> Dose G5o 14so_, I I MF,nr )C 1 1■ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plamber's PI MPMPRSNumber BrsiaesPhone Number <br /> Andrew W MeiMOz A-, 220165 608-831-810 3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6613 County Highway K,Waunakee'M 53597 ~~�\ <br /> VIII.County/Department the Only _ <br /> Na Approved ❑Disapproved <br /> Permit Fee Date Imt g Agent s __s�� , <br /> ❑OwneGiven Reason ter Denial /��� / � /isr 1 <br /> IX.Conffitiom of ApprwalR�ons for Disapproval '5L.. �1 <br /> hatch sowegdne slam its*exams.wad submit to the County est5 a napes newton thank N_ell mcha in size <br /> SBD-6398(R.11/11) <br />