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_ i \ L+i.. Y L..V County �J <br /> Safety and Buildings Division I Dane <br /> OCT 1 8 2016 201 W.Washington Ave., P O. Box 7167 Sanitary Permit Number(to be filled in by Co.) <br /> J Madison, Wi 53707-7162 <br /> Public Health MDC <br /> Environmental Ilea th <br /> rt • 3 State Transaction Number <br /> Janitary Ier tit Application <br /> In accordance with S?S 33321(2),Wis.Adm.C•-de;submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. :ote:Application forms for state-owned POVITS are submitted to Project Address(if different than mailing address) <br /> the Department of Sayer;and Protessionai Serviea_ Personal information you provide may be used for secondary /��, �] 7 <br /> paten=in accordance v.itn Lilt,Pri.ac: Lave,s_ S I4c.;(m),Slats. � }Gj C tJt 11.1+q 'r[fTt 1}U�4� L7 <br /> I I. A polication Information-Please Prin.:Ali_nformation <br /> Property Owner's Name Parcel r <br /> PA-rgJ.cK 5Q.0 HHoI....Z ( C10 HART ()E aoai,E. FU -D S)( oritt- 1 13 — s5y0 — <br /> ' Property Owners Ivlailing Address I Property Location <br /> 7923 A itkPOR.r goal) Govt.Lot t <br /> City,State ' Zip Code Phone Number h I,,.i h, S W %, Section (t <br /> Mu i)Lan-0 IL. t4../ 1 535 6,. . —LY1Lti <br /> N; R ( ) E <br /> II.Type of Building(check all that apply' Lot T °j <br /> ( 1 or Family Dwelling-Number of Bedrooms 5 ` Subdivision Name <br /> Blocky METES E . 0u.tt DS <br /> I <br /> ❑PubliciCamncrcial-Describe Use City of <br /> CSM Number O Village of 1 <br /> OState Owned-Describe Use J p� <br /> Town of C.OT'TPtC' . (tq.OvE <br /> li 1T1.Type of Permit: (C'necli only one box.on lie X. Complete line 3 if applicable) <br /> I A.' New System Replacement System OTreatment/Holdmg Tank Replacement Only ❑O her Modification to Existing System(e:p{ain) <br /> i O f <br /> I—� I List Previous Permit Number and Date Issued <br /> B. O Permit Renewal O Permit Revisic.a Change of Plumber OP. Transfer to l•few <br /> Before Expiration Owner ' <br /> IV.Type of POWTS S'istemfCamnoneatiDe'.dce: (Cheers ail that apply) <br /> I <br /> 1 Non-Pressurized In-Ground OPressutizecin-Ground OArGrade ❑Mound?24 in.orsuitable soil 0 Mound<24 in.of suitable soil <br /> OHolding Tank OOthcr Dispersal Component(=plain) OPretreatment Device(explain) <br /> V.DispersallTreatmcnt Area Information: f <br /> Design Flow(;pd) Desist Soil Application Rate(godsf) Dispersal Area Required(at) ' Dispersal Area Proposed(sf) System Elevation t <br /> '150 , - /072- 1 / 080 9/' ° � <br /> VI.Tank Info Capacity in Total r of ( Manufacturer <br /> Gallons Gallons Units ( B - m s <br /> Nctr Tanis 1 En-sting Tanl:s B E u i=L rz: <br /> Septic eetielding Tank i t9 5 S ;1( 0 <br /> IDosing Chamber 600 I Sod I P .i'A-)C-. X . <br /> IVII.Responsibility Statement-I,the undersign:d,assume responsibility for installation of the PM«'TS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/tvIPRS Number Business Phone Number <br /> Andrew W Meinholz _ '&1'1. 220135 608-831-8103 JJ <br /> I <br /> Plumber's Address(Street,City,State.Zip Code) <br /> 6813 County Highway K,Waunakee WI 83597 <br /> 1 VIII.County/Department Use Only o f Si lure 1 <br /> Permit Fee Date Issued �/��� <br /> pproved ❑ Disapproved 3 ,(3i l(0-1q-'24 ��II�`/ V <br /> Q Owner Given Reason for Denial "^i 1 I (.� <br /> L'G Conditions of Approval/Reasons for Disapproval OG�T 0� p r-n� �' <br /> 17 �ft�O h/t-7�i e�iYD��o� ��7 � G�.ti1'� �' /?�/L ore ��"�' <br /> 11,1Q'i�'dc�•(r( ti DRq�70 NY' R AD6D If - <br /> P/1 Q� �O math to comptetz alarm rrar thcssteat an submit to the Cauatc way am eager apt lets than 3[ftt zit inthm in size <br /> SBD-6395(R. II/Il) <br />