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;..,,,, County ;--\ <br /> j Safety and Buildings Division /✓o.Y`..om <br /> e . <br /> x D s - NOV 09 2016 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) t <br /> �� P S Madison,WI 53707-7162 <br /> �''',.,.- .-. Public Health MDC 1 "" r)°/6 00 bra <br /> °r Environmental Frealt,h <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. ApplicationInformation—PleasePrintAllInformation <br /> Property Owner's Name Parcel# <br /> Sc_o Cti o..sc �..-tC.A.s•& 74-C-",i 11-- 090-7 /53 611° o <br /> Property Owner's Mailing Address Property Location <br /> '/U c9.0‘--h ,..571"r‹e /4pf 3 Govt.Lot <br /> City,State r Zip Code Phone Number r/, y,, Section <br /> Prai8i c Dc, s,c- Gs) . S-35 7S <br /> T N; R e <br /> II.Type of Building(check all that apply) Lot# <br /> csa <br /> XI or 2 Family Dwelling—Number of Bedrooms v Subdivision Name <br /> Block# /J(,,r, /4.w/c i- ei. S <br /> OPublic/Commercial—Describe Use D City of <br /> CSM Number ❑Village of <br /> ['State Owned—Describe Use //�� <br /> CSITown of /`�UX.64'"X <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑Replacement System OTreatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> Cot!ft.e-t74-- <br /> B. ❑Chan List Previous Permit Number and Date Issued <br /> El Permit Renewal El Permit Revision Change of Plumber OPermitTransfer to New <br /> Before)expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Cheek all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized in-Ground DAt-Grade OMound'24 in.of suitable soil :Wound<24 in.of suitable soil <br /> ['Holding Tank DOther Dispersal Component(explain) * OPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units _ '- <br /> New Tanks Existing Tanks u T — e o = — <br /> J f r u..._ — <br /> Septic or Holding Tank I t ` <br /> Dosing Chamber _ <br /> VII.Responsibility Statement—I,the undersigned,assume responsibility for installation of the POVVIS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz ---- fit) - 220165 608-831-8103 <br /> Plumber's Address(Street,City.State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VI ounty/Department Use Only <br /> .,L-',�J Permit Fee Date Issued Issuing A.e. re/ <br /> Approved ❑Disapproved <br /> ❑Owner Given Reason for Denial <br /> $ � <br /> bit! I. ����_. .__, ,c�LL <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ,a2se/ edST/e/.er/,w /4051- ff. - f7f4e O ?,c1.-,c_ rc. r,ti4, /• e-7Asv4) <br /> I ' f' YNc 7---17.4 ,Vit4hN' OR DQ *fS IN . TWe A/eM4 TV n- )1 , ete;•a 0P 3. <br /> w l•,r.L Awe- / rt/ P e t.a., iiv <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x 11 inches in size <br /> SBD-6398(R.i i/11) <br />