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. . 6, 7 `608-831-8107 MEINHOLZ EXCAVATING 119 P03 DEC 11 '08 16:08 l'')) 6tilvikl-); EI •IF r ,; 'i� DEr 1 Q 21D ;W eommerce.wl.gov •-1 ■ Safety and Buildings Division-' County-� 201 W.Washington Ave.,P.O.Box 7162 I iS( OflSI n ` Madison,WI 5 3 7 07-71 02 Sanitary�P^crmilifNumlber(tohetilledinbyCa.) • DepWnmont of Commerce J 1 O Z 18 State Transaction Number Sanitary Permit Application In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for stale-owned POWTS arc Project Address(if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary �^ L PASS yr�'31 purposes in accordance with the Privacy Law,s.15.04(lxm),Stats. . u,VVIV)/T / I. Application Information—Please Print All Information Parcel q Prop Owner's borne ) �.1�„r�tn - AN-pkvi d�o8- ow- alG6 -o . S Property Owner's Mail :A.• s Property Location b. g L C 4S4 \O 1781 E lrvt wt�od nu e. Govt.Lot rf‘tdfti Q}�5354+2- �N�� City a Zip Code Phony Number r�Y' `!..�?E' :s. Section Q 531-s'l10 (�$ 833 X28� (circle os'c) T II.Type of Building(check all that apply) Lot 0 S 1 1.D Subdivision Name I or2 FamilyDwciting-Numbeof[lcdrooms c f _ . Block Su A-- ,,3 ❑Public/Commercial-Describe Use City of CSM Number ❑Village of ❑State Owned-Describe Use - 9 Town of Pc dd j�,je-r o` r III.Type of Permit: (Check only one box on line A. Complete line B if applicable) • • A. 7 New System ❑ Replacement System ❑Treatmcn/ifolding Tank Replacement Only ❑Other Modification to Existing System(explain) List Previous Permit Number and Date Issued B. ❑Permit Renewal 0 Permit Revision ❑Change of Plumber ❑Permit Transfer to New Before Expiration Owner IV.Type of POWTS System/Component/Device: (Check all that apply) 1;i4 Non-Pressurized hl-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.ofsuitable soil ❑Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Ratc(gpdsl) ' Dispersal Area Required(sQ Dispersal Area Proposed(at) System Elevation -I-S') O .62 1 a,S° - 11 a t/CD - qq**1 c(1--t1 q3,° Capacity in T,tal . II of Manufacturer / VI.Tank Info y '„ Gallons Gallons Units .o a' e _ New Tanks Existing Tanks yL' o Ii ' tldfiCa r �a[U in us i..t7^ 0+ Septic Of Holding Tank 1 f e ,,D 1(.,cc, . t o .- Dosing Chamber IOC) $00 •ea r_ _ VII.Responsibility Statement-1,the undersigned,assume responsibility for installation bf the POWTS shows'on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number Pfnli-t ) el.(\i(V:A-L. .../# 4 c . 6Z a() RR 5 _ /161 •8 31-$\0 Plumber's Address(Street,City,State,Zip Code) Ci'03 c-_--\ . 1-\oy . K, . 1 , a��nuKee t .t�� S 3S 9 VIII.County/Department�Only Permit Fee Date Issued Issuing Agent '. • ir pproved ❑Disapproved 0 Owner Given Reason for Denial s33-� 124 174 s ryr—, ..._— IX.Condition of ApprovaI/Rcasons or Disapproval E.l-eU a 3 1'7 °' Cat-r-'2- iM-C2-4c-l.'vt�urn*!`,•,: !,, ".P-11-,_iJR,[ ,NE CCUN C etf2A i.fci a • _J s, EN liHOlNMENIAL.-IEA.#_i•li DOES ,OT IIOLW)i(`,,-;_ LIABLE FOR ANY DEFECTS IN PLANS OR SP .i,1FHC A -PIONS.PLAN OMISSIONS EXAMINATION 05 R- Attach to complete plans for the system and submit to the County only on paper nut lest MVO kret1BTi1liCTION OR ANY DA.MAUL 1 lA i MA Ch V - -(0833- RESULT IN OR AFTER INSTALLATION AND RESERrE P� a�oa3 i Th'°RIGHT TO ORDER CHANGES OR ADDITIONS SBD-6398(R.01/07)Valid this 01/09 SHOULD CONDITIONS ARISE MAKING THIS NECESSARY