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County �1>�. <br /> R E C E I V � Safety and Buildings Division Dane <br /> `` $7 D- W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ` S SEP 2 2 2066 Madison,WI 53707-7162 11-eogo- 00G11-7 <br /> PtilAk Hwlth kik <br /> ,t:t. 4"" ' .State Transaction Number <br /> g�n�trt:�ikI4pplicatao :' <br /> In accordance with SPS 38321(2),Wis.Adm.Cr de,st;bmission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.t;ote:Application forms for state-owned POWTS 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 /� �j <br /> purposes to accordance with the Privacy Law,s.1 SAd('.;(m),Stets. A t r.p o RT' Ro A-D <br /> I.Application Information-Please Prinz All Information <br /> Property Owner's Name Parcel it <br /> LEC->-EKt0/rRY 1401V1 SS Lt-C• / ar708- G(cl- 1 1 $2,-0 J <br /> Property Owner's Mailing Address Property Location <br /> boo° E.xCEIrciot . LRitiE SUITE, 300 Govt Lot <br /> City,State Zip Code ' Phone Number S W 'A li E tIl,,Section <br /> M(r D I SO is) t f t t. 7 T. 7 N; R $ E <br /> er:U.Type of Building(check all that apply; Lot# Q` <br /> 211 or2 Family Dwelling-Number of Bedroom U a Subdivision Name ` <br /> l i✓N 1ST E.D. VAtd.S I tFST.�ADOLTIONI Block <br /> DPublic/Commercial-Describe Use <br /> ❑ll City of <br /> State Owned-Describe Use CSM Number L tLl�J•Village of <br /> Town of Mt00L.F_TUAJ <br /> 75I.Type of Permit: (Check only one box on Eae A..Complete line B if applicable) <br /> A" 21Nety System ❑Replacement System ❑TreatmenilHoldmg Taal:Replacement Only ❑Odrer Modification to Existing System(explain) ' <br /> B. 10 Permit Renewal O Permit Revisic.t ❑Change of Plumber Permit Transfer to Newt Previous Permit Number and Date Issued ) <br /> t <br /> Before Expiration It. Owner <br /> IV.Type of POWTS Svsteat/ComponentiDevke: (Check all that apply) <br /> ®Non-Pressurized In-Ground DPressurizec In-Ground Grade DMound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> DHolding Tank DOther Dispersal Component(explain) DPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) (Design Soil Applicoeip i i to ds c Dispersal Area Required(st) Dispersal AreaProposed(sf) System Elevation <br /> COO / • l�Applies/by /o00 //zS 1 9C.4 r9c.y q6-,-1- <br /> VI.Tank info Capacity in Total #of Manufacturer v di <br /> 2. °z'+ <br /> Gallons Gallons Units _ - v, <br /> New Tanks Esadng Tanks B a =C ° 's - <br /> a-V v:F rn a.0 <br /> Septic or Holding Tank t 200 1(aCo 1 1 µ-45A 0 - 1 <br /> Dosing Chamber 800 I / SOO l / r I 1 <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 MP/MPRS Number Business PhoneNumber <br /> Andrew W Meinholz ..2 W. - 220165 608-831-8103 <br /> Plumbers Address(Street,City,State,Zip Cod_) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIIL County/Department Use Only <br /> Permit Fee Date ed Issuing Age. : <br /> Approved ❑Disapproved S i d <br /> CI Owner Given Reason for Denial ' i I J' i6 � j1 - ' �' <br /> i <br /> IX.Conditions of Approval/Reasons for Disapproval 'EP 2 2 2016 <br /> Public Health MDC <br /> Environmental Health <br /> hymen.complete;tans tar tSse trm and subndt to the County oats on paper not toss than 8 hi z 11 inches in she <br /> SBD-6393(R.11/11) <br />