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:v T..',.,i.i_ County <br /> y: Safety and Buildings Division <br /> =r 1 0 P I'.I . 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by o.) <br /> S ,- Madison,WI 53707-7162 `` p <br /> ? \ F. /3-e)01-7' boo O-7 <br /> Sanitary Permit Application Same Transaction Number <br /> In accordance with SPS 38321(2),Wit 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 Scrvies. Personal information you provide may be used for secondary //�� y� (� <br /> purposes in accordance with the Privacy law,s_15.04(1)(m),Sacs- A.(eJr f /2OG c_ <br /> L Application Information-Please Print All Information <br /> Property Owwn�er's Name Parcel# <br /> Pei& C,C(9 1-I,,,ccc / 07.8-06 1— Bois-- 0 <br /> Property Owner's Mailing Address Property Location <br /> 77 83 f--)e-sfr t a.frt a.s-J / Govt Lot / <br /> ,r <br /> City,,Sttate Zip Cod Phone Number N£ ' ,J( 14,Section b <br /> i flat 1.e--kaA L..), S.3 s6 2- _ T 7 N; R ° E <br /> II.Type of Building(check all that apply) • # <br /> ❑I or2 Family Dwelling-Number of Bedrooms 1 1 2, / Subdivision Name <br /> � :$Ippk <br /> LlPublicfCommercial-Describe Use _ ❑City of <br /> ['State Owned-Describe Use CSM Number t{❑village of/ <br /> 'a.�- 3 i+Town of 1. drtl ,eLd) <br /> III.Type of Permit (Check only one box.on line A-Complete line B if applicable) <br /> f <br /> k "New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> / <br /> B. ['Permit Renewal ❑Permit Revision ❑Change of Plumuber aermit Trader to New List Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/CComponent//Device. (Check all that apply) <br /> lg./on-Pressurized In-Grow rr ['Pressurized ized In-Ground ❑At-GGrade ❑Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank l a aver Dispersal Component(explain) Dtnnca.went Device(explain) <br /> V-Dispersal/Treatment Area Information: <br /> Design Flow� Design Soil Application Ratc(grdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation , <br /> X12 . 4Y 66S /S /(d8 15.s, 4y s, 93.o/ 915 <br /> VL Tank Info Capacity in Total #of ` Manufacturer <br /> Gallons Gallons Units - `o'u v <br /> New Tads Existing Tanks u o ° 2 u .0 5 c <br /> 81 U' el)a, m t.O a. <br /> Septic or Holding Tank / '�I� ✓ -,,L/C//QO[.e,- yc <br /> Dosing Chamber (,Sc ✓ (c6 I cf..- JC_ <br /> VIL 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 — C.J. 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zrp Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VID- unty/Department Use Only <br /> Pewit Fee Date Issued Issuing-.-.t Signature <br /> Approved ❑Disapproved <br /> ❑Owner Given Reason for Denial S S / �f�v4��A:e''' " <br /> IX.Conditions of Approval/Reasons for Disapproval a— - ✓ L- <br /> APR 0 2017 <br /> � �® Public Health MDC <br /> Environmental Health <br /> Attach to complete plans for the system and submit to the County only on paper n ess than 8 1/L a 11 inches in sine <br /> SBD-6398(R.11/11) <br />