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R L--t,..L..1 V L.L.i , County gaiety and Buildings Division Dane •,,f OCT X 8 Lb16 i 201,N.Washington Ave., P 0. Box 7162 Sanitary Permit Number(co be filled in by Co.) J, son, WI 53707-7162 = Public Health MDC /3 -0014,__ e,{ v1-3S Environmental Health ry - d l Stare Transaction Number �az�?tary `'ermit Application In accordance with SPS 313.21(2),Wis.Adm.C.:de;suF3mission of his form to die appropriate governmental unit is required prior to obtaining a sanitary permit Nate:Application forms for state-owned POWYS are submitted to Project Address(if different than mailing address) the Deparhnent of Safety and Professional Series. Personal information you provide may be used for secondary pure in accordance with the Pr.i.ra•Lax,s. S.O4(i.;(an),Stats. I A T Z IZ©A D I I. A polication Information-Please Prin:All_reformation Property Owner's Name Parcel 4 DAK►K C O L/1\A 'i (C/o Inc KE(� Assoc t A-T-S-5, I . } 0S0'7 t L I - ecaoo- a j Property Owner's Mailing Address roperty Location 9 as VIA-rso hl A V E 0 u% Govt.Lot _ I City,State Zip Code Phone Number p Kr %, 14F %, Section I( M A D I SO KI t‘,.l l 5 3 T 8 v: R 7 E 1 II.Type of Building(check all that a , of R 01 or 2 Family Dwelling 'omb of Bedrootr.s Subdivision Name DAN CCW(� PI Vk Block �'1 ST S /�hltO 1301. /mil D S ubliciComm cial-Describe Use f"Ik' 'Z�(/WC Qrd — t �0 /�BNuea� F0Q -L City of ' ❑State Owned Describe Use PA4 K V[f( -.�,�f CS Number >�, I Village of 2 Town of g.P,i2\I IT!.'Type o€?ermit. "'neck;only one .t . " . io npiet`line 3 if applicable) I A. I Flew System [Replacement System [Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) i I —� i List Previous Permit Number and Date Issued ;3. ❑Permit Renewal E Permit Revisic t .tChange of Plumber Permit f ansferto New ; Before Expiration Owner I 1Y.Type 3Z?OWTS SvstemIComnoaentiDevice: (Check all that aaoly; 1[Non-Pressurized In-Ground [Pressurized In-Ground [At Grade Z Mound>24 in.of suitable soil 0 Mound<24 in.ofsuitablesoil � [,folding Tank [Other Dispersal Component(=lain) fPretreatment Device(explain) V.Dispersal/Treatment Area Information: Design Flow(_•pit Design Soil Application Rate(aodst) Dispersal Area Required(std i Dispersal Area Proposed(s f) e_ ' -T` VI.Tank Info Capacity in ' Total il of 1 ,Manufacturer ^T I Gallons Gallons Units I - . New Tanks E s -tine Tanks B - C .g.d -- ISeptic a-HotingTank 1(a 50 -- 1,I(050 a 1 ME1-A D 1 K 1 l 1 1 - I i I posing Clamber 8 vo i — I Soo . I 1 hh E A D i_ - I f I 11 Vii.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature NIP/IvMPRS Number Business Phone Number Andrew VV Meinholz �— (.t`,l� 220165 608-831-8103 Plumber's Address(Strxt,City,Slat:,Zip Code) 6813 County Highway K,Waunakee WI 53597 Vii.County/Department Use Only _'---- Permit Fee Date Issued ing. Si XA,sproved ❑ Disapproved S CI CA(0 ✓ /�.{ _ ❑ Owner Given Reason for Denial r c q— C` t TX.Conditions of Approval/Reasons for Disapproval fS �1f ` �.�/YfX0 f� 9. P�? -'r AAA/0 fps ^ ,�'( �v • for c Col -- -.9i-( SG f cA✓A-09;c / - I -:- --4/ htwch to compteta Szres•a,r t'mesgatem and submit to the Count outs on papas sot less thaa S L2 alt.inches in size SBD-6393(R. i I/I l)