Laserfiche WebLink
SCANNEDCounty Dane t+e/-� <br /> - Safety and Buildings Division <br /> ........24114V.Washington Ave., P.O. Box 7162 Sanitary Permit Number to be tilled in by Co.) <br /> - S P Madison,WI 53707-7162 <br /> S <br /> 41 Id-o/6 —6 Uz7P-- <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),Slats. PARK P-R PASS <br /> 1. Application Information—Please Print All Information I. ��j\ E <br /> Property Owner's Name y Parcel# <br /> NIC1401— C MAin-FEW TOO MIIZE SFP012016 C, 11 " 113 - OO4 .-O <br /> Property Owner's Mailing Address Property Location <br /> 1331 Qt I<E E AVENUE , a2.I I Public Health MDC Govt.Lot <br /> CIME gatal Health <br /> City,State Zip Code N k" '/a, 611,1 %r, Section 19 <br /> SUN r SA(1Zte_ w 53590 T , N; It. 11 E <br /> H.Type of Building(check all that apply) Lot# <br /> MI or 2 Family Dwelling—Number of Bedrooms <br /> 5 Subdivision Name <br /> Block# PA i&IcE12`S PLi\CE <br /> ❑Public/Commercial—Describe Use D City of <br /> CSIvI Number ❑Village of <br /> ❑State Owned—Describe Use <br /> IN Town of 5 R t S TO L. <br /> HI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' IN New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. El Permit Renewal ill Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground DAt-Grade ,Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> DHolding Tank DOther Dispersal Component(explain) DPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Dispersal I i <br /> Design Flow(gpd) Design Soil Appjcation Rate(gpdsf) Dispersal Area Required(sf) Area ro Proposed(s f) System Elevation <br /> ( (O v . /0 o I r 3 (1,2- i Sal- A T S!T _ <br /> VI.Tank Info Capacity in Total IS of Manufacturer <br /> -o U <br /> Gallons Gallons Units u 2 <br /> New Tanks Existing Tanks v 0° '' 2 u <br /> a.u rn u- 0 <br /> Septic or h1Old1ttg Tank l 1��i(s �_ F g-V, g t�j'- }4 g • <br /> Dosing Chamber 65 O ------ v o ' _ tl/i e- e D <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 — LA) 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Date Issued Issuing nt Si atu <br /> proved ❑Disapproved $/� �� I `�r'_,r <br /> I Permit Fee <br /> 0 Given Reason for Denial 1 wl a0 <br /> C...- 4011"\r- <br /> IX.conditions of Approval/Reasons for Disapproval /n n � /� �� �j �fLp <br /> (1�7�T lI'`°V`/�(1� s ft'7�/►', 119- ✓*Y i4,/� O ��Ctr.,.Q/L �2i'2�'e� <br /> Fir^ rag- cWy�O,q<-4a(; ,fot'G �c�rv, -T one /� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x II inches in size <br /> SBD-6398(R. 11/11) <br />