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3 <br /> IC;A County <br /> Safety and Buildings Division Dane .7frI) <br /> •a',- D _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �•,Sp S _ Madison,WI 53707-7162 <br /> ••h _ / -r;?Cs/4 •-00 r96 7 <br /> State Transaction Number <br /> Sanit�.ry F en-nit Application <br /> In accordance with SPS 38321(2),Wis.Adm.Cede,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. D+ote:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies.S Personal information yau�ravide may be used for secondary <br /> purposes in accordance with the Privacy Lew,s;S.tI0.(I)(m),Slats. R E C E'j[ B�� ����L ��� <br /> I. Application information—Please Prim All Information <br /> Property Owner's Name Parcel <br /> MR C VI-4 MADIN) Li-C. JUL 20 2016 0+705 203 - (o I 66 -0 <br /> Property Owner's Mailing Address Property Location <br /> Public Health MDC <br /> (t b0 I S^Lln To w N e. D R t V K Environ mental Health Goat.Lot <br /> City,State Zip Code Phone Number , <br /> IA A D i Su3J I s e 'A, S W /, Section J-0 <br /> T rl .N; R j} E <br /> II.Type of Building(check all that apply} 5 Lot <br /> gIor2Family Dwelling—Number ofBedrooms , 5 j 103 Subdivision Name <br /> / <br /> Block 4 S PR.0 c e ri 01.1..(J vJ <br /> Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> 2-Town of r''1) DU C,e.-'T G i`.) <br /> IIIi.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1New System ❑Replacement System ❑Treatmerit/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 121 Permit Revision List Previous Permit Number and Date Issued <br /> ❑Changeo�'Plumber �PermitTrnnsfertoNew <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground QPressurized In-Ground QAt-Glade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank Either Dispersal Component(explain) QPretreatment Device(explain) <br /> V.DispersallFrcatmcnt Area Information: <br /> Design Flow(gpd) Design Soil Applicatioon� CM- Dispersal Area Required(sf) r Dispersal Area Proposed(st) System Elevation <br /> - <br /> VI.Tank Info Capacity in — Total 1f of Manufacturer <br /> Gallons Gallons Units °13 ° <br /> - <br /> New Tanks Existing Tanks 2 O 2 2 O 3 <br /> _ <br /> Septic or Holding Tank I t�50 l i(050 .-1, 1-1 /ko F X � <br /> Dosing Chamber C<o a it SOC1 ` f,.tt De - <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 Signattud <br /> MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz J,,4._--• • '-v-- 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 8813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only ��, <br /> pproved ❑Disapproved Per�mfit Fee Date ed Issui g qg` eitl,5i�r <br /> ❑Owner Given Reason for Denial / 3/ /� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> attullt to compSNa slam for the system and submit to the County only on paver not less than B t2 ill inches in size <br /> SBD-6398(R.11/11) <br /> • <br />