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SCAN County <br /> E Safety and Buildings Division Dane ii )4- <br /> n S ZU1 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be fillsd in by Co.) <br /> P S Madison,WI 53707-7162 <br /> i 3-o,-a/6-G U..2-S-S <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 35321(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 POINTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s 15.04(1)(m),Stats. VAL MIA B Eu7 PASS <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel M <br /> \NilKbsOYL aulkRi24 LLC (C/o Akt131AIJc.E uotAES) 09 I( - (EA- 1533-0 <br /> Property Owner's Mailing Address Property Location <br /> 5 ,33 CslitekssLPtmo -1- Azi2,AcE Govt Lot <br /> City,State Zi.Cod Phone Number <br /> NE Mk(2suAU- W1 /535 5 %, sR 1/4,Section tS <br /> II.Type of Building(check all that a, ) Lot It <br /> T 9 N. R (� E <br /> TT,or 2 Family Dwelling-Number of B s 44 i 3 Subdivision Name <br /> Block# 31-11 .I\ 5 V'5 Rt0CIE <br /> ❑Public/Commerciai-Describe Use <br /> ❑City of <br /> ❑State Owned-Descnbe Use CSM Number ❑Village of <br /> ®Town of $el 5T 0 L- <br /> IB.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A' liin New System y ❑Replacement System ❑TreadttrnVHolding Tank Replacement Only ['Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑p List Previous Permit Number and Date Issued <br /> ❑Change of Plumber emit 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 ❑At-Grade }�{`'��ound>24 in.oof suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑other Dispersal Component(explain) ['Pretreatment Device(explain) <br /> V.DispersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> (Apo . C- /45eignar /A o, /Z.... S Er,ta-r S tre <br /> VI.Tank Info Capacity in Total H of Manufacturer <br /> Gallons Gallons Units = ti v o <br /> • <br /> New Tanks Existing Tanks +� j u— — <br /> o .e 2 .� <br /> -�G �t e.U v» H iE C —. <br /> Septic aibirhng Tart I p 1, ..� W & a. lei g-A D E <br /> Dosing Chamber 1 J_S.t l IPSO I I MGADIs JC <br /> VU.Responsibility Statement-I.the undersigned,assume responsibility for imstalladoa of the P0WI'S shown on the attached plans <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinho(z .....,..4. W - 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K.Waunakee WI 53597 �� <br /> VIft County/Department Use Only //���� <br /> fe�"!°pproved ❑Disapproved Permit Fee Dam Issuing A Si C `�y�� /"' <br /> ❑Owner Given Reason for Denial $4/4/‘, ' Z��Z�� t <br /> IX.Conditions of ApprovalReasons for Disapproval <br /> P� ., Pow(' f'ffT5N. St Arlo Al-ye GA /sr- <br /> P2Wte,s-pl°C room Jo - co '-' 'l l .lo/L Vr 0.(e, -1"to <br /> 17117 a(441. � zcr <br /> Attack to complete plans for the system and submit to the Carty Daly as paper not ter than It 12 1 1 1 inches is aim <br /> SBD-6398(R.I I/I t) <br />