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SCANNED County <br /> Safety and Buildings Division <br /> `D$ — —"201 W.Washington Ave.,P.O. Box 7162 Sanitary rermit Number(to be filled in by Co.) <br /> P S Madison,WI 53707-7162 <br /> -„ . _ ,c _ l.3 -av/ G -06) esG <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(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 provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stets. E [) PA R K E tZ PASS <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> PALA— c JuI.-1 etv-toP JUL 902016 oil - 193 003ti -0 <br /> Property Owner's Mailing Address Property Location <br /> Public Health MDC <br /> 55 I i kiil O i1D ca_r rJ ( RAIL_ Environmental health Govt.Lot <br /> City,State Zip Code Phone Number <br /> ty' p '/4, 5 ko ``V4, Section 1`3 <br /> MADiS(U'J V( 531 ( 40 T y N; R it e <br /> II,Type of Building(check all that apply) Lot# <br /> aor 2 Family Dwelling-Number of Bedrooms 4 "7 Subdivision Name <br /> Block# 1'ARk..e,(2.2S PLACE_ <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ['State Owned-Describe Use CSM Number ❑Village of <br /> Town of 8 IZ I c;1 O 1... <br /> III.Type of Permit: (Check only one box on line A. Complete like B if applicable) <br /> A. New System y ❑Replacement System ❑Treatmenr/HOlding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground lJAt-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(apdsf) Dispersal Area Required(sf) Dispersal Area Pro osed(sf) System Elevation <br /> U 0 I 0.( 1 1 I (7& I S i AT st1-E- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c „ <br /> t 1- c 5 J b r ya <br /> New Tanks Existing Tanks ` o - 2 3 ro <br /> cU c” A rn i= C7 - <br /> Septic or:Ndding Tank f Q.00 ∎s ( 1) 4 / M Ape '? I <br /> Dosing Chamber Qe �j i M A x <br /> VII.Responsibility Statement-I, - ity 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 /> ,pproved ❑Disapproved Permit/Fee/ Date Issued Issui gen i re 4114As______ <br /> ❑Owner Given Reason for Denial $ /W`r�.O 7-22� � C <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> fiefaitc_ 4- —G,R4D J7 a Arc lc 7 p 4.'tri p 4e/sl <br /> rO/L cDD►re c,-ria1 f f, c1,-C 1/4--Q. Yr 4W2' Ve at40- Ael,, cic <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br /> befik fa&AOVud- -9PY ‘<A4 0, (0 . <br /> M(/ I%tlIN Ptf(&Scic AZei Rev /40-Q7 s& <br /> SBD-6398(R. 11/11) <br /> P( s•f c,2 6 C A.e44 Pi 'T&9= (7 ci f . <br />