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County <br /> ,.cl n...4-, � <br /> G-•nt., J' <br /> r,,. Safety and Buildings Division <br /> 01W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> • 3a S S•' I=,i Madison,WI 53707-7162 <br /> 9,-.1 :o.),-"' State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to Me appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PORTS arc submmed to Project Address(if different than mailing address) <br /> the Deparanent of Safety and Professional Servies. Personal information you provide may be used for secondary / a..� <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stars. fr`>Lr''� <br /> I. Application Information-Please Print All Information Parcel# 1 <br /> Property Owner's Name 0 4,0 6 - 33/_ r.91 g D - <br /> ,,,73 Ct,.SOn y ° ; ✓ Property Location <br /> Property Owner's Mailing Address L <br /> Sir t e 7 Govt Lot <br /> ao� � ,. .'.></1-(., �' t s� =i Section 3 3 <br /> City,State 6 Zip Code Phone Number 1 /a, <, a ction <br /> _./11, /-404-c h W, . -G. -'7� T G N; R 6 E <br /> g apply) Lot# , <br /> II.Type of Building(check all that a "� ri Subdivision Name <br /> N1 or 2 Family Dwelling-Number of Bexiroo <br /> /'' _ <br /> Block# <br /> ❑Public/Commercial-Describe Use O City of <br /> CSM Number 0 Village of r <br /> 0 State Owned-Describe Use V 56e.1-7 Town of i ' )-4 4.4. �"� <br /> �� <br /> 1II.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. New System O Replacement System OTreahnent/Holding Tank Replacement Only ElOther Modification to Existing System(explain) <br /> L- <br /> List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber I lre rmit Transfer to New <br /> Before Expiration Owner <br /> N.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground QPtessurvtd In.Groundl` t-Grade OMound>_24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> O Holding Tank QOther Dispersal Component(explain)" /v 'Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area information: l � <br /> Design Flaw(Pd) Design oil Application Rine(gpdsf) Dispersal Ai"Required(sfl Dispersal Area Proposed(st) system Elevation a re udis, <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units :' ° <br /> New Tanks Existing Tanks ° °a U 2 o m <br /> t` in il oo _ <br /> t7 G, <br /> Septic or tfohtingTank /2_ e 6 /2-8‘ c0...-2. <br /> Dosing Chamber <br /> 6 L.1"; 65-.. i _ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz --. tO, 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) °` "` <br /> — <br /> 6813 County Highway K,Waunakee WI 53597 "-:C' <br /> -VIII.County/Department Use Only <br /> Permit Fee Date ed Issuipf Agent Si_,:4, <br /> proved ❑Disapproved $ t t t l ✓ /❑Owner Given Reason for Denial ``i .i/ ,p <br /> IX.Conditions of ApprovaUReasons for Disapproval L\---r(;,.. �' ^ $ Ipp_ re <br /> --R.-,---- .N. ,---,,. ( ""'": "27-.-% "if AY--- -i'g MAR 4 8 2017 <br /> and submit to the County only on not less than 8 rrz x 11 inches i'd- L 3 f=",;, �';JC <br /> Attach tornmpleteplansfortlresystem tY nlY paper Environmental Health <br /> SBD-6398(R. 11/11) <br />