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608-831-8107 MEINHOLZ EXCAVATING 030 P02 SEP 08 '08 13:56
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<br /> .commerce.wiltie SEP
<br /> — 26; "‘i';'' awil-In7Av.e.sPDOiviS13ox 7162 County
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<br /> !scans ni_.. . , Madison,WI'$3707-7162 Sanitary Permit Number(to be filled in by Co.)
<br /> Deportment of • . • •- i'Ix).,,.. i t: .r.; ";,';...s.: ' 1 Si g /,33
<br /> Sanit _ mac.Oil et id! ti- it State Transaction Number
<br /> . , - • 11 • Ili
<br /> In accordance with s.Comm.U.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental
<br /> unit is required prior to obtaining a sanitary pima 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.IS.04(1Xm),Stats.
<br /> I. Application Information-Please Print AU Information -Di lie CIV/Qv't Ct.
<br /> Property Owner's Name
<br /> Parcel ii
<br /> Guy Stvetz. k LAse).. 'RegrtiQ, . cace.—sp-4-6187-0
<br /> Property Owner's Mailing Address Property Location
<br /> 110 kniot..13 Tr.
<br /> eovt.Lot
<br /> City,State I Zip Code Phone Number se v SE. 'A Section .51
<br /> 4. .•lAintArtalatt Wi 5359-7 . _ (circle one)
<br /> T a N; R 6 E or*
<br /> II.Type of Building(check all that apply) Loci,
<br /> el or 2 Family Dwelling-Number of Bedrooms 5 24 Subdivision Name
<br /> •
<br /> Blnek tictit Rolle,
<br /> -f/. . ii.
<br /> 0 Public/Commercial-Describe Use -
<br /> • , 0 City of •
<br /> Use CSM Ntunber ' 0 Village of
<br /> 0 State Owned-Describe
<br /> 13/Town of sporeit-mtet
<br /> III.Type of Penult: (Check only one box on line A. Complete bite II if applicable)
<br /> A.
<br /> (!'New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification tramisting System(explain)
<br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Pennit Transfer to New List Previous Permit Number and Date Issued
<br /> Before Expiration Owner .
<br /> IV.-ype of POW'I'S System/Component/Device: (Check all that apply)
<br /> eiNon-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 /> El Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain)
<br /> V.DispersaVTrcatment Area Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation
<br /> 750 .4 ) 375 ts90 I crto 1—los,a/
<br /> VI.Tank Info Capacity in Total ti of Manufacturer 2 t
<br /> Gallons Gallons Units
<br /> 4 1 1 v i 1
<br /> New Tanks Existing Tanks 1
<br /> e, ii ., li iz a E.'
<br /> SeptieosiI4olding Tank I „50 ___ IC050 I Mt Aoll. A
<br /> Dosing Chamber
<br /> VD.Responsibility Statement-I,the undersigned,assume regoonsib ility for installation of the POWYS shown on the attached plans.
<br /> Plumber's Name(Print) Plumber's Signature W/MPRS Number Business Phone Number
<br /> AVIOttOoni W, Met 01,4012_ • 4-..-±si.,,— L-4_, el'-‘■-t?-1 ) 22o1(4.5
<br /> Plumber's Address(Street,City,State,Zip Code) .
<br /> (il:e>l C.14-k- V.ktia v‘et kee,I.N31 6393-7
<br /> VIT1.County/Department Use Only
<br /> Perrnit Fee - Date Issued Issuinent Signature
<br /> . gr-Approved 0 Disapproved
<br /> 5 .
<br /> a Owner Given Reason for Denial -3 20 60 9-5---08
<br /> —IX.Conditions of Approval/Reasons for Disapproval i
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<br /> - - . . •.;..-.., i:',1 j"i\MNIP v:•-),% •'
<br /> Attach to complete plans for the system and submit to the County only on paper not "tiln'ilt: x II sueltsii-uk. ,, A-J' tr:t. t.r Ai-,0... .1HAT mivr
<br /> IN: P E
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<br /> Th. ■-?.:,:i.',-;, I i 4,in`)t..1,cl-f , ..'•-' '',' s:
<br /> J...II7 Crk ADDadoptis
<br /> SBD-6398(R.01/07)Valid Vim 01/09 UI.D CONDi';"i A DNS ARISE MAKINti-I HIS
<br /> NECESSRY
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