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County E <br /> IVC <br /> Safety and Buildings Division <br /> D S _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> p Madison,WI 53707-7162 <br /> S <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 6ae-t-(-5(-I DA(Sy Courz3",/ <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> MR EC VP PlAolSO4 LL or7o8 - Z,o3 - 4o4Z -0 7 <br /> Property Owner's Mailing Address Property Location <br /> Cg bo( Sourn4 -T )144 ki E DR I V) Govt.Lot <br /> City,State Zip!,Ode Phone Number S(/J 1/4, (itj 1/4, Section c 0 <br /> M D LSD 1S W `7I T I N; R ? E <br /> H.Type of Building(check all that apply Lot# <br /> E0-1 or 2 Family Dwelling-Number of Bedro. s 5 il 1 ,,/ Subdivision Name <br /> / <br /> Block# S e I& t( r , ' -out r <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use /,� <br /> L. I T o w n of „'I 1 1)D(..'T t <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System / ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B f List Previous Permit Number and Date Issued <br /> ❑Permit Renewal ❑Permit Revision E Change of Plumber OPermit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ONon-Pressurized In-Ground/['Pressurized In-Ground at-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank DOther Dispersal Component(explain) Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> r75CG 7 - Lf / /8i5 7 /69 / 3.u <br /> /66-.� /oy.y/ o3.J�/a <br /> VI.Tank Info Capacity in Total 4 of Manufacturer o <br /> Gallons Gallons Units o '0 v_ <br /> o B _ <br /> New Tanks Existing Tanks " g , 2 II .8 2 2 <br /> aU H 0 ,Q a, <br /> Septic or Holding Tank LSO WS_S0 KA,e�D e x <br /> Dosing Chamber © 30 506 J MS Al)E <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installatioq 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 I G..) 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII ounty/Department Use Only - -"°` <br /> Approved ❑ Disapproved <br /> Permit ermit Fee . Date Issued ssuing Age re <br /> ❑Owner Given Reason for Denial 3N - m/, �� <br /> IX.Conditions of Approval/Reasons for Disapproval '`� <br /> p <br /> Public Health MDC <br /> rnvirnm <br /> oentAl Health <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x 11 inc es to size <br /> SCANNED <br /> SBD-6398(R. 11/11) <br />