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County t <br /> 5`• D Safety and Buildings Division Dane <br /> $P - 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> / S Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> in accordance with SPS 38321(21 Wis.Adm.Code.submission of this form to the appropriate governmental unit <br /> ' <br /> is requited prior to obtaining a sanitary permit. Note:Application forms d to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal informatio u de `I I purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. ` • i <br /> L Application Information—Please Print All Information i �L)�l 1.1504 i,��p <br /> Property Owner's Name MAY 1 1 2016 Parcel# <br /> vti m AcN Ut2.EA/US e.-4)250(0- 012- 1 1 b0 - 0 <br /> Property Owner's Mailing Address Public Health MDC <br /> Z 8G4 Environmental Health Property Location <br /> City.State Vd Au e sS A Av u,5 Govt.Lot <br /> Zip Coder? t Phone Number <br /> KA k 01 So hl liJ 1 15 3 ! 1 ) `.�5 '� lNL tJ ��c, Section t <br /> II.Type of Building(check all that apply) Lot# T S N; R Co E <br /> Ell or 2 Family Dwelling--Number of Bedrooms Subdivision Name <br /> �(PublidCommerciat— / Block/#'''��+TV �i�.s AL10 e� ./.1.0S <br /> Jot Describe Use Q f�/SAP 1)�•r[ Ir+ ED City of <br /> / ' 6 errs-vs. e.c s 4+�..+ <br /> °State Owned—Describe Use CSM Number,9 2016 0 Village of <br /> MAY 1 tj Town of MAZet Jai AIsi IF <br /> r <br /> III.Ty a 'errnit (Check only one box on line A. Complete line B it t g MD <br /> nvi Amen al Health <br /> ra New System 0 Replacement System DTreatment/HoId g Tank Replacement Only <br /> ❑Other Modification to Existing System(explain) I <br /> B• °Permit Renewal °Permit Revision ❑Chan a of Plumber List Previous Permit Number and Date Issued <br /> Before Expiration g °Permit Transfer to New <br /> Owner <br /> �rType of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized in-Ground °At-Grade ❑Mound>24 in.ofsuitable soil ❑Mound c 24 in.of suitable soil <br /> ElHolding Tank °Other Dispersal Component(explain) °Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area information: <br /> ,Design Flow(gpd) I Design SoilApplicadon Rate(gpdsf) 74reaRequired(sf) I Di ersal Area Pro sea/ po (sf) Sstem Elevation <br /> cf 37, ( 9ys ' <br /> VI. <br /> an Info Capacity in Total 15 of Manufacturer <br /> Gallons Gallons Uniis <br /> New Tanks , Existing Tanks u U <br /> " 0 6' u ro ° r- <br /> ot. r <br /> Septic or Holding Tank / D v a /000 f „Al Y <br /> e.A....4-, <br /> Dosing Chamber 6S-6 G rb ! e. / <br /> V.U.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 /> ,tv D Q W W M It(0 N ti z_ ____4_,____ (N <br /> ,::,1-4.._o l I 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee Wt 53597 <br /> ViII.County/Department Use Only <br /> Permit Feet Date Issued Issuing •: i: ature <br /> ❑Approved ❑Disapproved <br /> ❑Owner Given Reason for Denial $ t <br /> I 1�/)� 0,... ..e--1°. <br /> IX.Conditions of Approval/Reasons for Disapproval i+ ✓� <br /> i3/'f-2 5 <br /> Attach to complete plans for the system aad submit to the County only on paper not less than 81/2i 1 i inches in size <br /> SBD-6398(R.11/11) --. P 7110 ( 0252--1 <br /> � .w „ <br />