Laserfiche WebLink
, County <br /> Safety and Buildings Division Dane I 1 <br /> n„ 201W.Washington Ave.,P.D.SOa 7162 Sanitary Permit i lumber(to be filled in by Co.) <br /> Madison,VIII 53707-7162 <br /> I - Do I - oo3o L <br /> ► Slate Transaction Number <br /> Sanitary E ermit Application <br /> In accordance with SPS 38331(2),Wis.Adm.Cr de,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Senvien. Personal information you provide may be used for secondary <br /> r purposes in accordance with the Privacy Law,s. S.3C l(m),Stats. i 5 Vt i e Co LA R..r <br /> I. Application Information-Please Prin:All Information <br /> Property Owner's Name Parcel# <br /> iV►iZtC Vu MAOIso+U LL(_ r oi/08 - a03- 4.2.30- 0.r- <br /> Property Owner's Mailing Address Property Location <br /> 4 es O t Sca11-1 TON(\t e: U R 1 v E, Govt.Lot <br /> City,State Zip Code Phone Number Sri Iii, $t./ r <br /> /e <br /> �1V , Section i20 <br /> MAOisot't 11Ji 53'713 T I N: R $ E ..- <br /> II.Type of Building(check all that apply; Lot# <br /> gl or 2 Family Dwelling-Number of Bedrooms 5 .100 Subdivision Name <br /> Block# SP$LLt(.le Off-(-OVJ <br /> DPublic/Commercial-Describe UseR E C E I ! D <br /> 1 1� 0 City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use SEP 2 8 101G A A <br /> Townof 1�/\I OD1.g...-r0,J <br /> III.Type of Permit: C'neclt onl FI'h ..:li.e .mptete line B W applicable) <br /> A' [A New System D Replacement System I Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision r__,Change of Plumber DPerrlit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS Systent/CompmnentlDevice: (Check all that apply) <br /> ®Non-Pressurized in-Ground DPressurizecin-Ground QAt-Grade Olvtound DMound 24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank D0thcr Dispersal Component(explain) DPretreatment Device(explain) <br /> V.Dispersal/Treatmcnt Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(si) ' System Elevation <br /> 750 r I'�, -' 1 875 I d''% - 4Z.S.j is 0, cj ,c;9Y.o"'" <br /> VI.Tank Info OCapacIty in Total #of Manufacturer <br /> Gallons Gallons Units II 7, —' <br /> U g t. r <br /> Now Tanks Existing Tanks -. <br /> C.-.t� v:2 us i c7 <br /> Septic or Holding Tank I I V 5 o d- I s a 4.2 M E a D E > I <br /> Dosing Clamber 600 / 800 I ME A D 1. <br /> VU.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 Phone Number <br /> Andrew W Melnholz k 20165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued !satin! = ur <br /> Et Approved ❑ Disapproved �`�/ <br /> El Given Reason for Denial - <br /> P.C.Conditions of Approval/Reasons for Disapproval <br /> I <br /> .1ttaett to complete?tom for the system and snhmit to the County only an paper ant less than 3 us z II inches in she <br /> 1 <br /> SBD-6393(R. MI 1) <br /> i <br /> . i <br />