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County 1 <br /> Safety and Buildings Division ( Dane <br /> 201 W Washington Ave P.O Box 7162 l <br /> S a g Sanitary Permit Number Ito he tilled in by Coo i <br /> g Madison,WI 53707-7162 <br /> • <br /> 1 3-.)or6- po33) <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 3S3 2I(21,Wis.Adm.Code,submission of this tirm to the Jppropriare governmental unit <br /> is required prior to obtaining a sanitary permit. Nom:Application firms for state-owned POWTS are submitted to Project Address i if ditlerent than mailing addrssl <br /> the Department of Safety and Professional Sot-vies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Lass.s.1504111(ml-Stars. • ENI GtLIS“ DAISY COU.K(/ <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel P <br /> MREC V14 MADISo,J LLc_ / •4,02076 o'708- ...e-5- 40,75-o ..- <br /> Property O'.sner's Mailing Address Property Location <br /> I COSOI 501i 1-1-1 -1-01 40•1 DRIVE / Govt.Lot <br /> I City,State Zip Code Phone Number <br /> MI i}D iSOIJ 1,P 1 53113 s vJ s trJ :. section -2 o <br /> Q.Type of Building(check all that apply) // Lot Y <br /> T / N. R 8 E <br /> R.I or 2 Family Dwelling-Number of Bedroo s W r '75 , Subdivision Name <br /> BlockN St2.U.(.El. L-i-OLLC14J <br /> ❑Public:Commercial-Describe Use <br /> ['City of <br /> 0State Owned-Describe Use CSM Number ❑Village of <br /> I <br /> ®Town of MI DIL„t�TOI`) / <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' I g New S stem <br /> Y .,/IQ Replacement System ❑Treatment/Holding Tank Replacement Only []Other Modification to Existing System('explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber �ermit Transfer to New List Previous Permit Number and Dare Issued <br /> B ( <br /> Before Expiration Owner <br /> IV.Type of POUTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground at-Grade SSMound-24 in.of suitable sdllr❑Mound<24 in.of suitable soil <br /> Holding Tank ['Other Dispersal Component(explain) ❑Pretreatment Device(explain) - • <br /> V.Dispersal/Treatment Area Information: <br /> Designs Flogs'(god) Design Soil Application Ra[e(gpdsf) Dispersal Area Required(st) Dispersal�Area,Paropposed(sf) System Elevation <br /> OCl / /S U , . 46—t -� SET AT Sire, <br /> VI.Tank Info Capacity in Total Nor Mandy T <br /> Gallons Gallons Units E i <br /> New Tanks Esisting Tanks _ - C' - - <br /> u <br /> J .!n •n _,.: - <br /> Septic or Holding Tank <br /> �000 i .,2000 ( NleAOt X • <br /> Dosing Chamber 1 Iona r 1000 I MADE I X 1 , <br /> VII.Responsibility Statement-I.the undersigned,assume responsibility for installation of the POWTS shown oa the attached plans. <br /> Plumber's dame(Print) Plumber's Signature I MP/NIPRS Number Business Phone Number <br /> Andrew W Meinholz ....A-..-- (,J --+ � ,' 220165 / 608-831-8103 <br /> Plumber's Address(Street.City,State.Zip Code) <br /> tL.1 <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII„Eounty/Department Use Only <br /> �/ Approved ❑Disapproved <br /> Permit Fee Date Issued Issuing A. gnature <br /> 0 Owner Given Reason for Denial $ �d�V /Q f/ , `�/� rl`/ <br /> IX.Conditions of.Approval/Reasons for Disapproval <br /> r r /VOW,'0 sire' /A✓ irs /vfrk' - n-"vo1 n o•V• ,1/e 41/sue- , .v.e6 <br /> 6)ce4t04rran, <ap,.feT/e/l/, ore ✓e'/1/e4t.4t 1-4011-I*V%G. <br /> Attach to complete plans rot the system and submit to the County only on paper not loss than S 107.s I I inches in sit <br /> 5110-63 is(R. I Ii I la <br />• <br />