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Safety and Buildings Division 11/I- . I <br /> Vj' <br /> . <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co) <br /> .�P •` jai Madison.WI 53707-7162 <br /> ` - <br /> S •� 13- On - o°c4Gl 1 <br /> F_i<,...., State Transaction Number <br /> Sanitary Permit Application <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 are submitted to Project Address(if different than mailing <br /> the Department of Safety and Professional Scrvies Peersonm information you provide may be used for secondary C rut �AUC-a / <br /> purposes in accordance with the Privacy > <br /> I. Application Information—Please Print All Information Parcel# <br /> Property Owner's Name r ' I S c I! ---3"/(-- (0-,ZS <br /> /4;�/C-o(y lv op g /yeavle)u— /`b - (.2c•-c-- , <br /> Property Location <br /> Property Owner's Mailing Address Govt Lot <br /> Y8 y/ Feit...,ct_ /2J.- 3 y <br /> City,State <br /> Zip Code Phone Number r/., /1i i.. t/., Section <br /> a02-isorl W, . S37(ff ,.,.r3'7/ r T N; R 1/ E <br /> Lot# <br /> II.Type of Building(check all that apply) /�/ � � Subdivision Name <br /> �.l or 2 Family Dwelling—Number of Bedrooms <br /> Block# <br /> ❑PublicfCommercial—Describe Use <br /> 0 City of <br /> CSM Number ❑Village of n <br /> ❑State Owned—Describe Use 2 Town of J`C4-v‘ r"rA.'r( t' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ikl Replacement System ❑Treatment/Holding Tank Replacement Only ['Other Modi&c ation to Existing System(explain) <br /> aw System <br /> Change of Plumber Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision Owner <br /> Before Expiration <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground rrrssutized In-Ground ['At-Grade ['Mound>24 in.of suitable soil ['Mound<24 in of suitable soil <br /> Holding Tank ['Other Dispersal u Component(explain) <br /> ['Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Dispersal Area Required( I Dispersal Area Proposed(sf) I System Elevation <br /> Design Flow(gpd) Design Soil Application Rate(gpdsfj I / r( Z r ` 96.6 , q‘. <br /> 01/ <br /> / vC> I L( / SUp 1 <br /> lo I Capacity m Total #of Manufacturer <br /> VL Tank Info -I u o o <br /> Gallons Gallons Units �, U v 0 <br /> New Tanks Existing Tanks w`U m E V) a.0 a <br /> J --- 2&. Z J {ci..G�._ <br /> Septic or HoldieS'T'ank I'L U <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown noon the attached plans. Phone Number <br /> Plumber's Name(Print) Plumber's Signature I I 608-831-8103 <br /> 220165 <br /> Andrew W Meinholz L..„,21—■— _ 1".J - <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 • <br /> VIII. rouuty/Depttrtmpeo Use Only Permit Fee Date Issued Issuing Agent ign l�a�Vrn' <br /> Approved ❑Disapproved $ 140 I u�/2�(7 <br /> 0 Own <br /> er Given Reason for Denial l I Li <br /> C—/2 <br /> Conditions of ApprovaUReasons for Disapproval RECEIVED <br /> APR 10 2017 <br /> - Attach to complete plans for the system and submit to the County only on paper not less than 8 trzEnV IYOnrrrlf'T1r Health <br /> SCANNED <br /> SBD-6398(R. 11/11) <br />