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608-831-8107 MEINHOLZ EXCRUATING 947 P03 JUL 21 '08 12:21 Dg*. „44 _, a , Cris 4 ,41 q 4, Commerce. !I AA ++�jj ty . 4'.'. s Division County �I� E ZO l�iuwashi 7 A`ve.,P.O.Box 7162 t3lete, tis- ca n I Maths' ' 53707-7162 Sanitary Permit Number(to be fit led in by Co.) Deparboortt Pubic Health t+ 578 0? T ttttetl— !wan U, . : -I i -:•;t. e ' State Transaction Number Sani a 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 state-ovmed.POWYS are Project Address(if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary 9695 purposes in accordance with the Privacy Law,s.15.04(1)(m),Stars. I. Application Information-Please Print All Information Cig.Y Property Owner's Name Parcel 8 G1 it, art %e., IJt y • crc o-241-bSo1-o Property Owner's Mailing Address Property Location 102C0 ( ftt. Y Govt.Lot 24 City,State Zip Code Phone Number NW ,A, 1 %,Section (circle one) l 't'1:UtltRt thlk -.)".390,0 - T 9 N; R 6 EerAY- II.Type of Building(check all that apply) Lot A Subdivision Name Cl/I or 2 Family Dwelling-Number of Bedrooms 3 Black 8, ❑Public/Commercial-Describe Use - 0 City of CSM Number ❑Village of ❑State Owned-Describe Use LifiTovm of ikAtiltmtIrta2 III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System l7 Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) S. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner • IV Type of POWTS System/Component/Device: (Check all that apply) { Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil 0 Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.DlspersaVTreatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(si) Dispersal Area Proposed(sf) System Elevation .45D .5 `(, 0 VI.Tank Info Capacity in Total 8 of Manufacturer 2 a Is Gallons Gallons Units d E V o w _ 0 a era .8 - a co Ncty Tacks Existing Tanks it t j m ,S, to Is.O a. Septic or Holding Tank pc0 _ i 1 hetwci e cC Dosing Chamber m VII.Responsibility Statement- I„the undersigned,assume responsibility for installation of the POWYS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number -Awl - Metvn4 1. (,uV—l- i 220 PS e31. 51o3 Plumber's Address(Street,City,State,Zip Code) k2:1"6*([1k V v4 -'.L Wt 5359/ VIII.County/Department Use Only Permit Fee DataJiss/�ued/► Issuing A t Sign re Approved ❑Disapproved it 17/r su j(!S 1 ❑Owner Given Reason for Denial s3'^O' r ....--,_" IX.Condition*.f Approval/Reasonss or isapprrooval �� 7' X Jay RANTING THIS APPROVAL,DANE COUNTY / 5 �'�" � c�"`~� NVtRON E TA :A /I- DOES NOT HOLD ITSELF la A 111_ I a -aiir Ft1iLil►ae ' • N P _t ■s CA- Arta to complete plans for the system and submit to the County only on paper not ks WI i " ' 0M188i€NS,EXAMINATION OVER- SIGHT, CONSTRUCTION OR ANY DAMAGE THAT MA) RESULT IN OR AFTER INSTALLATION AND RESERVE: S13D-6398(R.01/07)Valid thru 01/09 Tk2 RIGH T TO ORDER CHANGES OR ADDITIONS SHOULD CONDITIONS ARISE MAKING THIS NECESSARY.