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`;..:��:vi1.). County r-� /� <br /> °: '' Safety and Buildings Division k..�4 -- I' <br /> . ''OS P •i`.i SCAN 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> $ Madison,WI 53707-7162 <br /> ``?,, \ _ I� / 3-- dot 7_ dew-7 , <br /> .e. <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 arc submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used ibr secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> I <br /> [ ".,/q,/G� L 1 c.--K-- /, 1 -/- - / f - .� --67o 6-- 6 t-f - 090 6 6— O <br /> Property Owner's Mailing Address Property Location <br /> 3744 --1,//s oA-4 04-1'k'.k--' Govt.Lot <br /> City,Stater Zip Code Phone Number s-t y,,.S. tin, Section Li <br /> 'LS� W , N3 a- T r/7 N; R o E <br /> II.Type of Building(check all that apply ! • . Lot# <br /> gl or 2 Family Dwelling-Number of Bedrooms y , . Subdivision Name <br /> Block# ,------ - <br /> ❑Public/Commercial-Describe Use ❑City of . <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use <br /> "/44 3-5-1 R Town of ,A4% doll'� ^ <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 QOther Modification to Existing System(explain) <br /> B. ❑Permit Renewal El Permit Revision ❑Change of Plumber OPermit Transfer to New <br /> List Previous Permit Ntmmber and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground QPressurized In-Ground QAt-Grade ,Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tanker Dispersal Component(explain) treatment Device(explain) <br /> V.Dispersal/Treatment Area Information: -.- ---"' <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required Of) Dispefal Area Proposed(ss System Elevation <br /> 6'64 _..---• (z> ,,./o0o Ir I 5(} 4?# f�� <br /> VL Tank Info Capacity in Total #of ` Manufacturer__. <br /> Gallons Gallons Units g°g <br /> V O ., an i <br /> New Tanks Existing Tanks 2 B $ 4 ,5 . <br /> a U rn vs s.0 P. <br /> Septic or Holding Tank /2 8 C /2S4 _2. '74- <br /> Dosing Chamber /s 61-4j _ / tt_ <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 h 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 /> �, Permit Fee Date Issued Issu' A:en •..•.r �- <br /> pproved ❑Disapproved <br /> $ 1)40 'y J <br /> \ ❑Owner Given Reason for Denial 429/i ` r + <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> P EC-z -iV <br /> MAR 2 3 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tfi s 11 Inches in size <br /> Public Health MDC <br /> Environmental Health . <br /> cRn-639R(R. 1 1/111 <br />