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.. 1 County / <br /> 33fer/and (C, (Buildings Division Dane c - <br /> = 201 W.Washington Ave.,P.O.Son 7152 Sanitary Permit Number(to be filled in by Co) <br /> ? I <br /> 1 bV Madison, WI 53707-7152 <br /> J i 00/(c.- 00377 <br /> S n to emit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Cede,submission of this furor to the appropriate governmental unit <br /> is required prior to obtaining a sanitary pemit i`ate Application forms for state-owned POWTS are ntbmitted to Project Addrss(if ditfa-.nt than mailing address) <br /> the Deparottent of Safety and Professional Setviea. Personal information you provide may be used for seconder, <br /> pumas=in accordance with the Pri:ac;Law,s`.S.W.)(m),Stars. ICALTE P.1 Pj��� pA5$ <br /> I.Application Information-Phrase P:in_Ali=aformatoa <br /> Property Owner's Name <br /> /� Parcel <br /> �F.(th1U5Gft t�ft.(.AKtz,y LLC (c/o ANLBmAhIGC 140M ES. I^IC.) 0911- 11,4 - (522_—O <br /> I Propel-Ey Owner's Mailing Address Property Location <br /> 5030 C-1-IZFSst_ANip T ,L4C Govt.Lot <br /> City,State I Zip Code 1 Phone Number <br /> MARSIA-re - W I 9 N /,, SE. /+ Y Section � <br /> T 9 N; R II E <br /> D.Type of Building(check all that apply; ��}} Lot f <br /> RI or 2 Family Dwelling-Number of Bedroom '1 y/ 11 Subdivision Name <br /> % Block at binRti15(7 Ni'S R I oc-tt-- <br /> DP'blic/Commercial-Describe Use <br /> CE 0 City of <br /> DState Ousted-Describe Use �0"dam of <br /> DEr0einos JTosserof e'es t5ioL <br /> ml 151.Type of Permit: (Check only one box on line ms. PPOila tap nine B if applicable) <br /> A New System Repiatcrtene S.stem LIT�11 Replacement Only Other Modification to Existing System(ceplait) <br /> B. ❑Permit Renewal I❑PermitRevisica LJChangeofPlumber 5ermit Transfer toNety List Previous Petmic Number and Date Issued <br /> f Before Expiration Owner <br /> IV.Tvpe ofPOWTS S'ystorlCsmonnent Dev`.cte (Cheek PH that ao'ly) <br /> ®Non-Pressurized In-Ground ❑Pressttrizec to-Ground 0At-Grade alound>24 in.of suitable soil D Mound<24 in of suitable soil <br /> DHolding Tank Dither Dispersal Component(explain) 0Pretreament Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application 2xte(_odsC Dispersal Area Required(at) Dispersal Area Proposed(Sf) 'System Elevation <br /> ,00 cC i-i�a 94,3`t99,Z' <br /> ( L � , 9q,01 <br /> VI.Tank Info Capacity in Total d of I Manufacturer - <br /> Gallons Gallons Units - - ' <br /> -P. ,d U� _ <br /> New Tanks I sdna Turbo I Li o B ., 2 x — <br /> e.0 u....-14 r it 1= <br /> Septic ogioliingTank (era 6, 1 —. I i � .o - kI EADE l 1 I I I l <br /> Doting Chamher ob.0 I 1 CiSv 1 I Mt<Ikon 1 I 1 1 <br /> VII,Responsibility Statement-I,the andersignad,assume responsibility for installation of the POINTS shorn on the attached plans. , <br /> Plumber's Name(Print) Plumber's Simature MPMiPRS Number Business Phone Number <br /> Andrew W Lieinholz __..-L_,_. {,.•% V 9_00165 608-831-8103 <br /> Plumber's Address(Street,City,State Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only ....".") <br /> Appmved Q Disapproved P®it Fee Date Issued., Curios S' <br /> ❑Owner Given Reason for Denial 3 q"J i -- 12--13-2016 I`6y F'1 <br /> I <br /> IX.Conditions of Approval/Reasons for Disapproval t <br /> i <br /> Mod.no tvmptec stem Tor the strums and submit to the Cmtnty only rs paper not Ins't."2 Ut o It inches in sire <br /> SBD-6393(R.I I/I I) <br />