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County <br /> Safety and Buildings Division Dane <br /> 3 S�„ . _ SCAN N 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> /3-.2v/4 -Cf0a-sy <br /> Sanitary F ermit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Cede,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permiL Vote Application forms lbr sate-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 <br /> purposes in accordance vid,.the Privacy Law,s.13.14 C.1(m),Slats. <br /> I Application information—Please Print All:nformahon R E I Y F D <br /> �}U Z SG i V ��% 0 e1 <br /> Property Owner's Name Parcel <br /> 0 <br /> J EFF KE t-A t.111) Allfi 2 2 Plffi O810-2-5Z-9553-,3 ./ <br /> Pmp_erty Owner's Mailing Address . Property Location <br /> / <br /> 16t 05 Sly LI+.ft I E 1 rV �R iv E Public Health MDC Govt Lot <br /> City,State Zip Code c1(AXItattt0Il Iva Ith <br /> 5 F_ v:. Idw /.t,Section 25 <br /> Siti 4 PRIIiR,t 101 53590 r e) N; R (0 E <br /> II.Type of Building(check all that apply; Lot 3 <br /> RIot-2 Family Dwelling—Number of Bedrooms (..P / 3 Subdivision Name <br /> Block <br /> DPublic/Commuciel—Describe Use <br /> 0 City of <br /> ['State Owned—Descnbe Use l CSM Number �❑q village of <br /> { ,69e DaTovmof E,u q„.,K,t <br /> BT.Type of Permit: (Check only one box on line A.Complete line B if applicable) <br /> A. �New S tern ❑ mg Only ❑ g ' <br /> ys ❑Replacement System Treatmrnr/Hoid' Tank Replacement Onl Other Modification to E>dstin System(=plain) <br /> B. ['Permit Renewal ❑Permit Revisits ❑Change of Plumber ❑Permit Transferto New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS SystemlCotuponentiDevices (Chtccelkall that apply) I <br /> ®Non-Pressurized In-Grounty 0Pressurizec l <br /> zec In-Ground _jAt Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Oita Dispersal Comporr_nt(explain) tment Device(explain) <br /> V.DispersaVfreatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(godsf) I Dispersal Area Requited(sf) Dispersal Area Proposed(sr) System Elevation <br /> 900 `t i1I �Rsc: ,;2.2--5c p4.5;g8.o' 97,Y/96.5".r.. <br /> VL Tank Info Capacity in Total k of Manufacturer s <br /> Gallons Gallons Units r '° e <br /> � ° 0 55tt ;;rr <br /> New Tanks Eelsting ratan n`. g 'rr.a ri: .rte- b <br /> Septic or Holding Tank it>4.3.ee,„r 0OO `T IIojLocn °- MADE I <br /> Dosing Chunber i 1- fe r'1 h's3 CX7" 1 M lti AD F_ <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 �r —�-- J JJ MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz �..- w', J 220165 608-831-8103 <br /> Plumber's Address(Slier.City,State.Zip Code) L <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.Coonty/Department Use Only <br /> ❑Approved ❑Disapproved Permit Fee Data Issued lssumg _. <br /> S y3/.-- / 8/26/ /�Tf.- '� <br /> ❑Owner Given Reason for Denial �s/ / <br /> /'i� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ■trach w complete plum`.or rtxayssm and sabrntt to are Coaaty eats wpapnr not lac thong um a 11 inches in size <br /> 3BD-6393(R.11/I1) <br />