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. 608-831-8107 MEINHOLZ EXCAVATING 258 P02/03 MAY 18 '09 11:37 <br /> 1 I - - Safety and'13Ulldings t)lvjsioII """'r <br /> `' 201 W.W •:'Ave..P.P.Box 7162 {Y1p <br /> . • * <br /> ScOn him ' 4 20podison IS).53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Corn <br /> 66-3151 5719.28$ <br /> State Plan I.D.Number <br /> SanitarytPgranp;rr.cation <br /> In accord with Comrr 83.21,1 u( 1art~ad'et .etSoytaltplformatioh,you provide • <br /> may be used for secondary purposes Pnvacy w,s 5:114(d)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information • 51g 'KW?, r3 <br /> Property Owner's Name Property Location <br /> ,icyry Ljavie_ KrU SE % SE. / Section 2'7 <br /> Property Mailing Add T S N R I2 H <br /> 15 tSe-dtre St <br /> City State Zip Telephone Parcel# <br /> Wesi iikvr.4'1 a 4516 C's12--2-14- `S <br /> Type of Building (Check all that apply) Subdivsion Name/CSM# Lot# <br /> X 1 or 2 Family Dwelling—Number of bedroom . CS 71,.1 3057 1 <br /> D Public/Commercial-Describe Use 0 City 0 Village 1)11 Township of <br /> O State Owned—Describe Use YOrk ' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. pf New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System <br /> Ii. 0 Permit Renewal 0 Permit Revision 0 Change of 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> 'Ion-Pressurized In-Ground 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil 0 At-Grade 0 Single Pass Sand Filter <br /> O Constructed Wetland 0 Pressurized In-Ground 0 Holding Tank 0 Peat Filter 0 Aerobic Treatment Unit 0 Recirculating Sand Filter <br /> Cl Recirculating Synthetic Media Filter 0 Leaching Chamber 0 Drip Line C1 Gravel-less Pipe 0 Other(explain) <br /> V.D 'a eatment Area Information: <br /> gn Plow(gpd Design Soil App1 Rate(gpdsi) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 4 1,,25 l,i28 c l.v'- So, St <br /> VI.Tan o Capacity in Total No. Menu acturer Prefab Site Steel Fiber' Pla- <br /> Gallons Gallons of Concr Con- Glass stir <br /> New Existing Units struct <br /> Tanks Tanks <br /> Septic o iisrdatg Tank .., koo — i COO 1 )e446 X <br /> Aerobic Treatment Unit <br /> Dosing Chamber /r,..) — eal7 i tt X <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 Signature 28P/MPRSW No <br /> 'AndtA,,,/ W. 1v1tYtkC12.. 220166 <br /> Plumber's Address(Street,City,State,Zip Code Phone Number(Daytime) <br /> 0313 CM. %Z. WaurtAKee.1 WI 53937 e8 1. 0103 <br /> VIII.County/Department Use Only <br /> )kpproved . 0 Disapproved Sanitary Permit Fee(incl Date Issued <br /> W Surcharge Fe. <br /> // <br /> Reason Owner for n 36 l 7 <br /> Reason for Denial. I' -, <br /> IX.Conditions of Approval/Reasons for Disapproval IN,,: , <br /> hib Al'1•HLIVAL, DAN!_ COUNTY <br /> ENVI ' NM yi AL HEALTH DOES NOT HOW IT Lit <br /> LiA.,_E FOR .IY DEFECTS IN PLANS OR SPEC!'ICA <br /> TI.- S, PLAN OMISSIONS, EXAMINATION OVER- <br /> S BHT,CONSTRUCTION()R ANY DAP✓IAG-THAT Al <br /> RESULT IN OR AFTER INSTALLATION AND RESE'VEt <br /> TH:RIGHT TO ORDER CHANGES OR ADDITION' <br /> SHOULD CONDITIONS ARISE MAKING THIS <br /> NECESSARY. <br /> • <br /> Attach pieta plans(to the County only)for the system on paper not less than 81/2 i I1 inches In size <br /> 91 <br /> chIL- lifq 303. 4t Rea.o D <br /> SBD-6398(R.01/03) • . <br />