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�-=' • Coun <br /> Pirre ty <br /> Safety and Buildings Division Dane <br /> v SCANNED 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> � <br /> x.523 Madison,WI 53707 7162 <br /> , <br /> /3—20'4 —60?--t J <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Cc,de,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit_i: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 1 <br /> in :.i.lFnjotmatj RECEIVED �µQRSC.Nt tUA l) ./ <br /> 1.Application information—Please Prim All=mformahon <br /> Property Owner's Name Parcel <br /> J EFF KELP(41) AIIG 9,2 YU1R 0e,10—251-9 553—,3 <br /> Property Owner's Mailing Address • Property Location <br /> 6t 05 STONEH-AVER DR.IvE Public Health MDC Govt Lm <br /> City,State Zip Code RK4iiaggert etol I IeaIUi i <br /> 5ut4 PRAi(z,ic. v4.11 53590 SE N�(1 Section 25 <br /> IL Type of Building(check all that apply) Lot 9 T p) N; R 0 E <br /> [RI or2 Family Dwelling—Number of Bedrooms Co / 3 Subdivision Name <br /> '' Block 4 <br /> DPublic/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use I CSM Number 0 Village of <br /> ', 5e al Town of gURte.,1= <br /> 1)lt.Type of Permit: (Check only one box on line A..Complete line B if applicable) <br /> A. New System ❑Re Replacement System <br /> ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ../ <br /> I �'l <br /> 8- ❑permit Renewal ❑Permit Revision El Change of Plumber DPernit Transfer to New List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS Systcm/ComnonentiDev Set (Check all that amply) <br /> ®Nan-Pressurized ln-Groundf ❑Pressurizedln-Ground ❑At-Grade ❑Mound>24 in.ofsulablesoil 0 Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I <br /> " I Design Soil Application Rate{ggodsf) [Dispersal Area Required(sf) Dispersal Area Proposed(st) Systems levation r ,, <br /> 9 0 o CC��/� ‘2. ,5-0 a , d2r s(c / 72_s,9B.o� 97,.% 9G.s ■ <br /> VL Tank Info Capacity in Total S of Manufaeturw _ <br /> Gallons Gallons Units —' <br /> c ' o'o _ 5 <br /> No:Tanks Sistine Tarts o = —C ',∎ ° _ <br /> Septic orliotding Tank , o00 T I, lC() off- MEAoE II �X I <br /> Dosing Clamber / 4t)-43.ee-- I moo I 1 t"t g Ao F=' 1 "' I I <br /> VII.Responsibility tatement-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 Phone Number <br /> Andrew W Meinholz _.,4______.--- t-c _ 220165 608-831-8103 <br /> Plumber's Address(Street,City,State.Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/i)epartment Use Only <br /> ❑Approved ❑Disapproved Permit Fee Date Issued s ��1.ao/ Issuing. r <br /> ❑Owner Given Reason for Denial 8826//6 2'/" <br /> IL Conditions of Approval/Reasons for Disapproval ' // <br /> .Osach to eomprem?tam:or MO system and submit to the Comity cols on paper not tea ttana 112 cll inches in size <br /> SBD-6393(R.11/11) <br />