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608-831-8107 MEINHULZ EXCRVHIING iii - i DE: kl '08 17:32 <br /> t: iir._ --- _-. _._ • fI <br /> • ,� ; <br /> De- a7(p(o( C I/‘,759-77-- <br /> oommercO.vvIgov Safe !Buildings Division County <br /> 201 W.W);Shington Ave.,P.O.Box 7162 �j rem <br /> SCO �' „- , �,r(a'dison'WI 53707-7162 Sanitary Permit pNumber((to�be filled in by Co.)• <br /> tin Deportment of v_i 1. 'rte - _".'______,-_' �) 6 2 i 4U <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with t.Comm.8321(2),Wis.Mm.Code,submission of this form to the appropriate governmental , <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,s.15.04(1)(m),Scats. Ce IL 01Ls Gf rL PPS <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel b <br /> { (,(d Stmt./0z- v"]i,7_ i2--9-14-1- 1 <br /> Property Owner's Mailing Address Property Location <br /> 343 141C,(!C it 1 _ Govt.Lot <br /> City,State tp Code Phone Number y., NMJ /, Section 1 <br /> (circle one) <br /> Je4-i 1rtf 1/J1 • �✓ T N; R l Ecal <br /> Il.Type of Building(cheek all that •■ Lot if <br /> ,.,� 4 f Subdivision Name <br /> p11 or 2 Family Dwelling-Number o r. s J <br /> Block U, <br /> O Public/Commercial-Describe se • • 0 City of <br /> CSM Number 0 Village of j� <br /> O State Owned-Describe Use (YTown of t t�j S [ yi5 <br /> 152 . <br /> III.Type !Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. L`7 New System ❑Replacement System O Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal ❑Permit Revision 0 Change of Plumber O Permit Transfer to New <br /> Before Expiration <br /> Owner <br /> IV.Type of POWTS System/Component/Device: (Check/II that apply) <br /> O Non-Pressurized In-Ground ❑Pressurized In-Ground At-Grade O Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> El Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rarc(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elf vatiorr a �! <br /> s Se- c_vl( i <br /> VI.Tank Info - Capacity in Total il of Manufacturer It t <br /> Gallons Gallons Units e g v 2 <br /> - y <br /> New Tanks Fxistng Tank s 4:-." cn i <br /> cs.U as vs w 0 n. <br /> Septic aaiioldntg Tsnl ,2 s i! 1 M cs )e <br /> _- <br /> Dosing Chamber — l-Y .) ( \♦ )( <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 I ivfP/MPRS Number Business Phone Number <br /> q .4 riA,2)(1- ,_<(,x___. T/ ____- ill 22)1 .3_ l �JJ�- td <br /> Plumber's Address(Street,City,State.Zip Code) <br /> Gi3 . V^"-i-t-fiv . I wi [36s:>-7 <br /> VIII.County/Department Use Only <br /> �/ Permit Fee ' Date Issued Issuing Agent Si:. .' re, <br /> "(Approved ❑Disapproved $, <br /> JJ 18 3. OC) /�Ja S�C 1./ 2'n) / <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> IN G•• Iv I Irv!; ■HS APPROVAL, DANE COUNTY <br /> ENVIRONMErNTAI_HEALTH DOES NOT HOLD ITSL!.L <br /> LIABLE FOR ANY DEFECTS IN PLANS OR SPECIFICµ. <br /> TTIIOONNS, PLAN OMISSIONS•EXAMINATION O P_ <br /> - Ailoch to complete plans for the system and submit to the County only on paper not less�f}H•a'IVr a WIN IN OR ANY DAMAGE THAT P✓11r.� <br /> RESULT IN OR AFTER INSTALLATION AND RESERVE; <br /> THE RIGHT TO ORDER CHANGES OR ADDITIONS <br /> SAD-6398(R.01/07)Valid thru 01/09 SHOULD CONDITIONS ARISE MAKING THIS <br /> NECESSARY <br />