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f <br /> County <br /> Safety and Buildings Division Dane 8 , <br /> D; ' SCAN N D1 W.Washington Ave.,P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P 3' Madison,WI 53707 7162 / <br /> i3_ 4-0►1 — 0009 <br /> �.l i t a State Transaction Number <br /> any Permit Application <br /> In accordance with SPS 38321(2),Wis.Adm.Crde,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. P:ote:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Pe sonal information you provide may be used for secondary <br /> 1 putposes in accordance with the Privacy Law,s`:S_f4(i;(m),Stats_ L(D t NI P o A O / <br /> L Application Information-Please P rip_All_iformation <br /> Property Owner's Name Parcel <br /> 1 EVINI £ L4u12rL Lic i cu c c/o MAr -rEd BUILD11,161A-ND DE51(44) e9(0-- 354- (o/OS -O <br /> Property Owner's Mailing Address ' Property Location <br /> 170 2OK 1,04 Govt.Lot <br /> City,State Zip Code ' Phone Number <br /> SUM PrZA121e (A.I I 53590 SC V. SE �. Section 35 <br /> II.Type of Building(check all that apply Lot# T 9 R 1 E <br /> Ell or 2 Family Dwelling Number of Bedrooms 4 / I g Subdivision Name <br /> Block g S CH-12GEDE R'S FL ELI) <br /> DPublic/Commercial-Describe Use <br /> City of ` ' <br /> (late Owned-Describe Use CSM Number Village of VJ 1 1Q O 5 G R. <br /> DTown of <br /> ii5.'Type o€Permit: (Cheep only one box on line A. Complete line B if applicable) <br /> A. <br /> ©New System D Replacement System DTreatment/Holding Tank Replacement Only ❑Other Modification to Existing System(etplain) <br /> B• D Penni&Renewal 0 Permit Revisica ❑Change of Plumber ['Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration I Owner <br /> IV. ype of POWTS Systt:tn/ComponentDevice: (Check all that apply) <br /> Non-Pressurized in-Ground ❑Pressurizes In-Ground 0At-Grade ❑Mound>24 in.ofsuitable soil 0 Mound<24 in.of suitable soil <br /> DHolding Tank ['Other Dispersal Component(r:plain) DPretreatment Device(explain) <br /> V.Dispersalrreatmcnt Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(_gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st)/' System Elevation <br /> t/00 • l ti-C- o /.-/Z /_ <br /> VI.Tank Info Capacity in Total R of Manufacturer t. <br /> ' , <br /> Gallons Gallons Units r ti <br /> , ? <br /> New Tanks I EzistingTanks `0 e. 2 <br /> C 3 <br /> o.t J r m so <br /> I i=C.1 <br /> Septic or Holding Tad: ` Iclei(0 -1 11.1e4, ` I��/�() ( . < I f 4 I . <br /> Dosing Chamber LI 5 0 /( 10 5 o I 1 1 M E 4(7 E I .> • J 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 /' �, 220165 608-831-8103 <br /> Plumber's Address(Street City,Stare,Zip Code) +-- <br /> 6813 County Highway K,Waunakee WI 53597 <br /> County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ' (4sf 61 2 ' / �� <br /> ❑Owner Given Reason for Denial .m/`i /-j ��I I a <br /> IX.Conditions of Approval/Reasons for Disapproval / <br /> RECEIVED <br /> JAN 2 0 2017 <br /> inch to comptett:?Into the system and submit to the County only on paver eat less than t In.all inches in size <br /> Public Health mOC <br /> ? <br /> Environmental Health <br /> SBD-6393(R. 1 i/I1) <br />