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608-831-8107 MEINHOLZ EXCAVATING 083 P02 OCT 30 '08 12:39 <br /> • <br /> 1• r . <br /> sit .ro 961 7c. 0.6. ) .2 Silo7 <br /> cornmeroe.Wtgcsv 2-9 ty and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 lne. <br /> 1 i Madispn,WI 53707-7162 5Permit gr(to be filled in by Co.) - <br /> t/� _ <br /> Sanitary Permit Application State Transaction Nnrilber <br /> In accordance with s.Comm.8331(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 arc 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.tS.04(lXm),Stets. <br /> I. Application Information-Please Print MI Information a'PP,t-abt-u tr Rd- <br /> Property Owner's Name Parcel 8 • <br /> • S • •e c 06- 35t-9-1e5-cam <br /> �. $ RP-f�ec - .-= <br /> property Owner's Mailing Address Property Location <br /> 12 46 -1-h:Y►{,ta4 Lit• Govt Lot • <br /> City,State Zip Code Plume Number 'M 'y., NE k, section 35 <br /> MGl'.l t soil r bJ I 53-119 T e N R 8((circle o one) <br /> II.Type of Building(check all that apply) Lot ft <br /> Ell or 2 Fasay Dwelling-Number of Bedrooms 4 1 Subdivision Name <br /> Block-#. . <br /> 0 Public/Commercial-Describe Use • - 0 City of • <br /> CSM Number 0 Village of <br /> 0 State Owned-Describe Use 7 <br /> Io S [ own of r15-Re'VI <br /> - <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A• riNew System r 0 Replacement System 0 Treatment Holding Tank Replacement Only 0 Other Modification to'Fxisting System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner • • <br /> IV.Type of POWTS System/Component/Device: {Check an that apply) <br /> 'Non-Pressurized In-Ground ❑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) 13 Pretreatment Device(explain) <br /> V.DispersalfFreatment Area Information: • <br /> Design Flow(gpd) , Design Son Application Rate(gpdsf) Dispersal Area Required(sf) ' Dispersal Area Proposed(at) System Elevation <br /> (,00 ,4 I Sop _ IpZ 9a 31-9731 <br /> VI.Tank Info Capacity in Gallons Units Manufacturer B o v o <br /> New Tanks Existing Tanks . w i ' w 6° a <br /> 0 <br /> Septicoo ottliaTask 12e0 -- IZ% i Mende X <br /> Dosing Chamber Epo — &'0 t lit. X - <br /> VII.Responsibility Statement-I,the undersigned,assume responsiblllty for installation of the POWTS shown pa the attached plans. <br /> Plumber's Name(Print) Plumber's Signature /MFRS Number Business Phone Number <br /> Aeve4 tt'nn.r W• Me r h l 2- — W 2201E75- 53 i-3103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> C- 13 • C:n-t- K 1Naurtal��.e l still .5.3 -9-7 . <br /> VEIL County//Department Use Only _ <br /> Permit Pee Date Issued Issuin ant Signature <br /> Approved 0 Disapproved <br /> . s337. 0O /0-30-O _r <br /> 0 Owner Given Reason for Denial . <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> iN GRANTING THIS APPROVAL DANE COUNTY <br /> ENVIRONMENTAL HEALTH DOES NOT HOLD ITSELF <br /> LIABLE FOR ANY DEFECTS IN PLANS OR SPECIFlCA <br /> TIONS, PLAN OMISSIONS,Ee4M1NATION OVER <br /> Attach to complete plans for the system and submit to the County only on <br /> paper 00t i t�iAN� lt: V-1DR ANY DAMAGE THAT MAY <br /> RESULT IN OR AFTER'INSTALLATION AND RESERVE: <br /> THE RIGHT TO ORDER CHANGES OR ADDITIONS <br /> SBD-6398(R.01/07)Valid thru 01/09 SHOULD CONDITIONS ARISE MAKING THIS <br /> NECESSARY. <br />