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I - ,RECEIVED County <br /> Safety and Buildings Division _ `- <br /> AUG 2 2 2016 201 W.Washington Ave.,P.O.8ox 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S I Madison,WI 53707-7162 / <br /> . Public Health(ADC I /5-�C�ri -'(0�'1,S <br /> 1 <br /> Envuanmenta►_ki t'lth <br /> Sanitary i emit Application State Transaction Number <br /> In accordance with SPS 2S32I(2),Wis.Adm.C-de.submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit i'otr_.ppiimtion forms for state-owned POWIS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Pe.-,opal information you provide may be used for secondary �t 7D� (��t <br /> purposes in accordance vath the Pti-acy Lary:,s. S.(}':(:(m)StatS. CA R O 1 N Ad— 1 r�i h l l T15 1 L <br /> I.Application information-I' ; •'p 1J ,-tf�-mssjgn <br /> Property Owner's Namrr"�/ a,Z ' _pert E.7 LLB_. \ - Parcel <br /> (10 'eV�(}Eltlt-Ivtz ECLAVartnll,i 1Gr-o?v8—ZU3—Z335i —p <br /> Property Owner's Mailing Address(t 1�,," 1/ / Property Location <br /> (Di 3 CC L I V i-1-11.7, T)A l k Govt.Lot <br /> City,State Zip ode Phone Number n <br /> p v�1/.+ %, S Y�1 '/,Section ZQ <br /> UJAuNA-Ki t i I 1 535, "1 Los-& i-6103 <br /> II.Type of Building(check all that apply: Lot R T 7 N; R 8 E <br /> 27sor2 Family Dwelling-Number ofBedrooms G ! Aj Q Subdivision Name ' f _ <br /> Block s / v V 9 1tAC E 140 L.4..ii v <br /> ❑Public/Commcrcial-Describe Use <br /> 0 City of <br /> QState Ovmed-Describe Use CSM Number ❑V/lag e of i <br /> I t....----.12trovm of I\/l j 1)I)i£_1 l)t- <br /> 151.Type of Permit: (Check only one box on• . . otnptete tmEllifappiicahie _ \ <br /> A' ❑New System ❑Replacement S. ®Trtazmentfl lolling Tank RAplaaawatt.Only- )Other Modification to Existing System(e:plait) <br /> • <br /> 1'-t i e -1 List Previous Permit Num.ber and Date Issued F <br /> B. I Pemit Renewal ❑Permit Revisic 1 I!0Change of Plumber 11-Permit Transfer to New <br /> 19e ce Expiration I I Owner it 0 340 CAI v 105 <br /> IV.Tronof?O;;'S System/Component Dev.ce: (Checkallthatapply) <br /> ❑Ncn-Pressu, edIn-Ground ❑Pressvrizecln-Ground ❑At-Grade g Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank DOther Dispersal Compon_�t(e.hplain) ❑Pretreatment Device(explain) <br /> i V.DisbersaliTreatment Area Informato s: <br /> ,l Desist Flow Lnnpd) I Desist Soil Apolicaul Race(spdsf) Dispersal Area R red(sf) Dispersal Area Proposed at) System Elevation <br /> I x150 I C',(, 1 ��/'`C' ;2Sc' 1 4..1q4/1- 99.2 <br /> VI.Tank info ry In of ter( R of M ufacturer __ I - I <br /> Gallons Gallons Units j i I <br /> d <br /> New Tanks S Fthsdng Tanks `Z - C <br /> I( 11 I atJ I v m :n C.ry ^ I <br /> I Septicur Holding Tank I /1,050 iil4��0 t "ft€AoY >< I j I i . <br /> Dosing Chamber I 1 500 I I D,l•,�. I M C.AO bD t X <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W kleinholz -.A^ IitJ --------t-: 220165 608-831-8103 <br /> Plumber's Address(Street.City,State.Zip Code) <br /> 6813 County Highway K,Waunakee'A 53597 <br /> VIE.County/Department Use Only <br /> pproved ❑Disapproved <br /> Permit Fee Date ed - �' <br /> S C09,0°ry Ab <br /> Q Owner Given Reason for Denial 3 ..........,,, <br /> IX.Conditions of Approval/R sons for Disa?proval <br /> v <br /> Mtwara,compltic?Sam er:hesztm+and suhmtt to the County only m paper not less than 8 tat x 1t inches in size <br /> SBD-6393(R.11/11) <br />