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County <br /> Safety and Buildings Division Dane <br /> 7 201 W.Washington Ave.,P.O.Box 7162 rtaty ( by <br /> S p Madison, 53707-7162 San Permit Number to be filled in Co.) <br /> S <br /> `� RECET cn 3 �i cb <br /> Sanitary Permit Application State tansaction Number <br /> In accordance with SPS 383_21(2),Wis.Adm.Code,submission of this form to the apsi,,Y inr24 �q <br /> is required prior to obcainmg a sanitary permit.Nose:Application forms for state-owned POWTS are loci to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you prov*b�tc be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xml,Slats. qua' tUt MDC PA V C(�Y <br /> L A lication Information-Please Print All Information >:n Jit�t teTCrlt31 i fB2ti(1 ��Ac <br /> Owner's Name <br /> is <br /> TEFF A o SAtI.y .J�4nt5 N il8- O(,4- ((.Z2-0 <br /> Ptupc y Ounces Mailing Address //�� CC Property Location <br /> { L5 C2icK-E-- LAhre S Govt lot <br /> City.State Zip Code Phone Number ✓ / <br /> Eft°DLr✓ � l&L 1 53Sfo2 �r /, S� '/-'Q.Secz;on (n <br /> IL Type of T ' N; R 8 E <br /> Ype Building(cheek all that apply) 4 Lot <br /> FlI Of 2 Family Dwelling-Number of Bedrooms 4 L./ 12 Subdivision Name <br /> Block it CK j DELL ESTh-rES <br /> ❑PublicKommerrial-Describe Use <br /> ❑City of <br /> I ante Owned-Describe Use CSM Number ❑Village of <br /> IR Town of O1q <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A New System® Yst CI Replacement System ❑Treatment/HOlding Tank Replacement Only ❑Other Modification to Existing System(explain) JI1 <br /> B- ❑Permit Renewal ❑Permit Revision ['Change of Plumber Germ it Transfer to New us' iGusPermitNumber and DateIssued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/C pones/Denier (Check all that aPPlY) <br /> ❑Non-Pressurized In-Ground In-Ground DAt-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in of suitable soil <br /> ['Holding Tai* her Dispersal Component(explain) -IS h 0Pretreajment Device(explain) <br /> V.Dispersalff tmeat Area Information: (C!C <br /> Now(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) , Dispersal Area Proposed(st) System Elevation <br /> 1000 0s 3 W', ; — ' & , 7,', , <br /> VI.Tank Info r Capacity in frond k of Manufacturer t <br /> Gallons Gallons Units ° e it o <br /> Non Turks :sst'ing looks R , <br /> 2 c aU _ n r C <br /> ) tf <br /> Septic or Holdrng Tank t�OO 's2.b0. sA I Mt . ` <br /> ' <br /> > Chamber <br /> Bon boo 1 t,i,j4 DE. x <br /> VII.Responsibility Statement-I.the undersigned,assume respoasibitity for instalatiaa of the POWTS shown oa the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinhotr — (,.).l't� 220165 608-531-8103 <br /> Plumber's Address(Sues,City,State Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Perini Fee Date Issued -•'.'•Agent Si".-:..- <br /> ❑Owner Given Reason for Denial S 1 j! ik / _ "�_� <br /> IX. ns of Approval/Reasons for Disapproval <br /> I�e.1 C4.6±.1....-,A � ec S . L , y -�'1 . <br /> Attach to complese pens for the systeat and sabsit tithe County osly on papa not lea than a its s I l inches in sire <br /> SBD-6398(R-11/11) <br />