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County OI i <br /> Nrw= �A ✓�� IC j 7 <br /> �_' �'•s, Safety and Buildings Division <br /> :Y', 0 <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S P 1�1 Madison,WI 53707-7162 <br /> �` /-7 000‘„0 <br /> S • <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),W is.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 fbr secondary <br /> purposes in accordance with the Privacy Law,s.15.04(IXm),Stats. -PC 14 1tS Ti/V 0£Ai RCrg <br /> I. Application Information—Please Print All Information Parcel# <br /> Property Owner's Name // <br /> g°f2 wl J n <br /> 6 ,,rr��tt/ )< LA-eiC Lt,IC_ o11/ - ,14 `/- 9S`6o- v <br /> Property Owner's Mailing Address Property Location <br /> 6 6, s, /v-✓ C-i r.6 t'tr Govt.Lot <br /> City,State I Zip Code Phone Number Ni 'n, Sl t/4, Section ol 40 <br /> 3c4.i r-r.- VI bS c `f/ T . -7 _ N; R- /( E <br /> - <br /> H.Type of Building(check all that apply) . Lot 4 <br /> Subdivision Name <br /> g 1 or 2 Family Dwelling—Number of Bedrooms <br /> 'Block P <br /> ❑Publie/Commercial—Describe Use ❑City of <br /> CSM Number ❑Village of <br /> DState Owned—Describe Use //‘ G v Town of C,/7 aq r Gro V e. <br /> -III.Type of Permit: (Check only one box on line A. Complete line B if applicable)) J <br /> A. aNew System D Replacement System ❑Treatment/Holding Tank Replacement Only ['Other Modification to Existing System(explain) <br /> List Previous Permit Number and Data Issued <br /> B. ID Permit Renewal ❑Permit Revision <br /> ❑Change of Plumber permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> I'Non-Pressurized In-Ground ['Pressurized In-Ground DAt-Grade ['Mound>24 in of suitable soil ['Mound<24 in of suitable soil <br /> ❑Holding Tank ['Other Dispersal Component(explain) ['Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 75.-v , c/ /67S /8 `Io /vg_ v'/u6 .v /6yo� <br /> VL Tank Info Capacity in Total P of Manufacturer , <br /> Gallons Gallons Units 1 A <br /> i . i <br /> Tanks E ° E u <br /> New Tanks wag a.U in tb ) ir.o P. <br /> Septic orHeiding Tank /6 S',- — /65-6 4,-- rJ e ex.:.--- <br /> Dosing Chamber <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 ✓"► \----- 1.0. 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIIL County/Department Use Only <br /> Permit Fee Datc Issued Issuing Signature <br /> X...kpproved ❑Disapproved S q / <br /> ❑Owner Given Reason for Denial 400\ �1s�t� C , I IX.Conditions of Approval/Reasons for Disapproval ti <br /> �/6.�� _ MAR 1 4 2017 <br /> Public Health mix <br /> Environmental He.:it•h <br /> Attach to complete plans for the system and submit to the County only oo paper not less than 8 to x 11 Inches in she <br /> SBD-6398(R.11/11) <br />