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' J <br /> Safety and Buildings Division n e— <br /> J44-- <br /> '�..\$P i-:.201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI 53707-7162 <br /> Permit Application <br /> State Transaction Number <br /> Sanitary� PP <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 Se:vies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(lXm),Sacs c%/-1 C.- ., <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name `✓/ <br /> �Pareelaeso`7 oy � �/7.-yc, <br /> • - -� - • <br /> � 1.7 1;64, l Lose.✓ e5.54-✓ ' : <br /> Property Owner's Mailing Address 'Property Location <br /> JOq e-:0 /': <br /> ✓'C• Govt Lot �[ <br /> City,Stare Phone Number L g '% 5f4J vs Section <br /> .1*. / C �; Oi 5-8-460S,..--460'-,..-- T $ N; R 7 E <br /> IL Type of Building(check all that apply /Lot 0, , <br /> X1 or 2 Family Dwelling-Number of Bedroom" \,... Subdivision Name <br /> j s Block a o, QG%c.. C... <br /> ❑Public/Commercial-Desaibe Use <br /> ❑City of <br /> ❑State Owned-Describe Use N umber \ Village of <br /> 11-14 /) IR Tom of P foSC <br /> III.Type of Permit (Check only one box on line A. Complete line i a 1' ble)— <br /> A <br /> New System ❑Replacement System ['Treatment/Holding Tamk Replacement Only ❑Other ModiSeffiion to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑change of Plumber OPermit Transfer to New Lim Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ At-n <br /> Pressurized In-Ground ad ❑ <br /> e Mound>24 in.of suitable soil ['Mound<24 in.of suitable soil <br /> ❑ <br /> ❑Holding Tank Other Dispersal Component(explain) OPreereamrent Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate( Dispersal Area Required(sf) Dispersals Proposed(sf) System Elevation <br /> VL Tank Info Capacity in Total 0 of Manufacturer - <br /> Gallons Gallons Units ` `o- u <br /> New Tads Tads o L)u - <br /> E g g Y. E `0 2 m <br /> o <br /> ,r n.[J in a in t V G <br /> Septic or Holding Talc /O J O 705-0 2- _e0 Oe `t <br /> Dosing Chamber G 0 0 600 / ter{, P. <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/sv1'RS Number Business Phone Number <br /> Andrew W Meinhoix _A-- \ 220165 608-831-8103 <br /> — <br /> Plumber's Address(Sheet,City,State,Zip Code) v <br /> 6813 County Highway K,Waunakee WI 53597 , <br /> e''' `^ - <br /> VIII.County/Department Use Only m <br /> Approved ❑Disapproved Permit Fee Dare Issued Agent Si_.� � <br /> ❑Owner Given Reason for Denial 14(4."."-- �Y/� r • <br /> D1 Conditions of Approval/Reasons for Disapproval ( «. <br /> .:......SCA NED <br /> -? t_. 4 zTtdz.s v.l-,s R i 1)/1 7 <br /> Attach to complete plans for the system and submit to the County only on paper not less than a vs s 11 inches m Mae I <br /> SBD-6398(R.11/11) <br />