Laserfiche WebLink
\,1"..:,,.'1t. _.... County '\ <br /> Safety and Buildings Division LDar�. <br /> • s P• , '� 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) c, <br /> • s Madison,WI 53707-7162 <br /> r' / 3— ;O/7—Oeno 1 i <br /> N f,. <br /> Sanitary Permit Application State Transaction Numbs <br /> In acoordance with SPS 383.21(2),Wis.Adm.Code,submission of this twin to the appropriate governmental unit - <br /> is required prior to obtaining a sanitary permit.Note:Application forms for stale-owned POWTS we 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.I5.04(lxm),Stag. "-GA( V■lit✓ t / <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel ti <br /> St.-11G-5 13ct e�0. Da.n lfia.. Do� (L /6So7— 17,-- 966o - 3 �' <br /> Property Owner's Mailing Address Property Location <br /> 63 fir-/ Ca SCA/V441 G.-r Pi/al-G Govt.Lot <br /> City,State / Zip Code Phone Number SLeJ 'Y, )I(Al '/, Section /7 <br /> De 7'v'r'c.1 i / A , . 535-3, -. T N; R 7 E <br /> IL Type of Building(check all that apply) Lot/ <br /> 01 or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑Stare Owned-Describe Use CSM Number ❑Village of <br /> 9 6 Ey / 5iTownof aC,./1 / <br /> IIL Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. 'New System ❑Replacement System ❑Treasmeot/Holding Tank Replacaneta Only ❑Other Modification to Existin g System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber DPermit Transfer to New List Previous Permit Number and Dare Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized trI--n---llGrand ❑Presstnized In-Ground (JAS-Grade Mound>24 in.-�ooffsuitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank LJUmer Dispersal Component(explain) OPretre anent Device(explain) <br /> V.Dispenaalffreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Cod / , ■ / .,/0 6 0 /775" 5cf-(0 SA, <br /> VL Tank Info Capacity in Total a of Manufacturer <br /> Gallons Gallons Units s `o e, v <br /> New Tads Eivacog Tacks o c°o er e S a 2 = <br /> n.U ov ri a, ri D C. <br /> Septic a Holding Tad /Z p 6 /2-e a ✓t.)ta�'e' i <br /> Dosing Chamber !_ -C> . /-5 / r? X _ <br /> U. <br /> ✓ 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 �T 1J — 220165 / 608-831-8103 <br /> a <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> )7County/Departmeat Use Only <br /> proved ❑Disapproved Permit Fec Date Issued Issuing Agent Signanre <br /> ❑Owner Given Reason for Denial I I � �,l s ., _....,.:e/ <br /> DC.Conditions of Approval/Reasons for Disapproval ,AI 1 v I <br /> SCANNED APR 1 2 ZDU <br /> Public Health MDC <br /> Environm.n,._ - <br /> system to complete plans for the syst and submit to the Comity only oo paper not less them 8 in 11 incites in aim a' ' )i=e I Cr <br /> SBD-6398(R.11/11) e <br /> s <br />