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608-831-8107 MEINHOLZ EXCAVATING 074 P06 OCT 22 '08 10:47 <br /> 1 ° .i !keGk To 'Sg.31 06 0 .77/././9 <br /> comillerCe.�.gov UL I 1 6- 20 e�f t)t--,Bi uldings Division County <br /> 201 W.Washingtoh Ave.,P.O.Box 7162 Dare, <br /> meg. Mff °''T is 53707-7162 -Sanitary Permit Number(to be filled in by Co.) <br /> / r 4. 5 • 8 <br /> S anita Permit Application State Transaction Number r} <br /> In accordance with s.Comm.53.21(2),Ws.Adm.Code,submission of this form to the appropriate governmental eP e "okra, T' ( 71- <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy law,a.15.04(lXm).Stats. <br /> I. Application Information-Please Print AU Information ut'wA 1'r'O{ -Tr- <br /> Property Owner's Name Parcel f <br /> • <br /> E"wre Cons-t •tc1Ltn &SoLQi I teveloprKgrd 0SQ3- 313;0023-O <br /> Property Owner's Mailing Address Property Location <br /> 4X55 l nyt rs(n"et"4 C-#• Gad.Lot <br /> City,State Zip Code PhoneNumber WE 'V, 1'JW 1/4,Section 31 <br /> wrong( r W l 3 T a N. R e5 (circle <br /> H.Type of Bnihling(check all that y) Lot P <br /> ��,,// 3 Subdivision Name•m l or2FamilyDwxlling_Numberof Moo( <br /> B1pdGd'. <br /> 0 Public/Commercial-Describe Use _ 0 City of • <br /> CSM Number 0 Village of <br /> 0 State Owned-Duman Use 1l(Town of rte ir■J"tit a <br /> • • <br /> 1D..Type of Permit: (Check only one box on line A. Complete use B if applicable) • <br /> A. 0'// w System 0 Replacement System 0 Treatment/Holding Tank Replacement Only v 0 Other Modification to Existing System(explain) <br /> Previous Permit Number and Date Issued <br /> List <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change <br /> of Plumber I ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> gi4on-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound/.'24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: . <br /> Requized{� Area Proposed( System Elevation <br /> Design Plow(gpd) Design Soil Application Rate(gpdst) I Dispersal Area <br /> 900 .4 2/250 <br /> VI.Tank Info Capacity in Total li of Manufacturer <br /> Gallons Units a 1 $1 <br /> New Tanks >istinsT . 7 a <br /> V Ns Wt7 p• <br /> Softie wadding Tank ?G1.,0 2eXX) 1 MEAM ME. )< <br /> Dosing Chamber I � -' t c I x - - <br /> VII.Responsibility Statement-I.the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Signature 'foP/MPRS Number Business Phone Number <br /> fMd ww k+ 100‘ <br /> 12 _ t 0 �Yt,. 122ot�5 153 t•,SI63 <br /> ket3• CI AA 1% VJCtt,cm..V ( L t, 535.31 . <br /> Viii.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee 00 Date Issued Issuing Agent Si Lure <br /> 7 �/ r� r <br /> 0 Owner Given Reason for Denial 1 S✓7/7 T b—/,` O <br /> IX.Conditions of ApprovallReasons for Disapproval 4f ,, .;:r:rr f;,t• nafr <br /> . .+,•::'f 0; <br /> Attach to complete plans for the system and submit to the County only on paper not lest than 1113 s l.iochet to Aft I.! so y <br /> • <br /> I i it:l <br /> SBD-6398(R.01/07)Valid thru 01/09 <br /> • <br />