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:-y: County R !1 R E C E I n Safety and Buildings Division Dane v _ E QA�!W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) ' \ S4 S- - SEP 0 5 07- 2 zo §donio k�iV� 16:3-._ �� a _ Q002 7/ E ►'QOU eafth-MD Application State Transaction Number �tIT PP In accordance with SPS 38331(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit tote:Application forms for state-owned POWI'S are submitted to Project Address(if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Lpaposes in accordance with the Privacy Law,s'S p4('.)(m),Stars. P/4 R K ER Pfd S S I. Application Information—Please Prim_All=nformation Property Owner's Name N k Ini 66.J 1.1 Gj : 5R Ati1 E Parcel •MARI"EN gult_DiNt1 F OFSi(-11 1 IN( l KRISTA it,11LA-1N L. . G911-- 193 - OU5lo- ci ✓ Property Owner's Mailing Address Property Location Cat 4 60 Nil ILL-STC U E. Src,t Govt Lot City,State Zip Code one Number r 19 r Res-r `N 1 ( 53 2 'A. S%iJ /s, Section IL Type of Building(check all that apply 2 T `� N; R ( ( E 241 or2 Family Dwelling—Number ofBedrooms 1.17 Subdivision Name , \.....5 lock# - PA Rice=ik 15 PLACE OPublic/Commereial—Describe Use 0 City of ❑State Owned—Describe Use I CSM Number Village of ®Town of BRt.Toi III.Type of Permit; (Check only one bay on line A. Complete lines if applicable) I A. K New System ❑Replacement System DTreabmcet/Holding Tank Replacement Only 00ther Modification to Existing System(explain) B. Q Permit Renewal ❑Permit Revisic z ❑Change of Plumber ❑Permit Transfer New List Previous Permit Number and Date Issued i E Beare Expiration Owns IV.Type of POINTS System/CamponentrDevice: (Check all that apply) Non-Pressurized In-Ground OPressurizecIn-Ground QAt-Grade DMound>24 in_of suitable soil O Mound<24 in.of suitable soil Holding Tank DOther Dispersal Comporesit(explain) DPretreatrnent Device(explain) I V.Dis ersa11Treatment Area Information ci. .r -r.3' y . ' V7,3' Y- ., AreaPro Proposed ystem�levatiofi ' - Desiri Flow(gpd) Design Soil Application Rate( Disposal Area Required(sf) Disposal p 96.3 `✓.. '150 i. y /8�S ✓9a5 Eta. ,1g ' - Total # Mannfarturert2 „"`, VI.Tank Info Capacity in = �- Gallons Gallons Units F. =a e. 3. V° F u = 7 New Tat F�stine Tans H = —° C / �f L✓U ci as l i L' t7 Septic or Holding Tank 1 L.50 MAO -2 1 MCAue T�/ I } Dosing Chamber • I Ivi C 4 D i= X VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POSITS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number Andrew W Meinholz _ €-0, ' 220165 608-831-8103 Plumber's Address(Street_ ity,State Zip Code)om _ — _` 6813 County Highway K,Waunakee INI 53597 VIII.County/Department Use Only ❑Approved ❑Disapproved Permit Fee Dale St /�'r/ f Owner Given Reason for Denial S T .,/ i IX.Conditions of Approval/Reasons for Disapproval ' ?12,04c1— _f/IiA Aflet i 44-Asevvr .ft + 1144, 4eE¢ IS ,,. r S<'P /,v /tS 1 ttriA fit L- Co N O tT 10 et) . t1Je 1)1'4'14 Si-h-4-00 c G- 644 4-v . Am_ ✓ L/tt�Nr.AR- I tbrfl v-- 41r14AwE V.• Varad4soevmp_ebe alms tort stem and submit to the Counts outs as paper ant1ess than it zn xiI inches in size SBD-6398(IL 11111)