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,�.t;:.t,t County <br /> Safety and Buildings Division Dane 1M <br /> 0 S . _ 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> r p s ! Madison,WI 53707-7162 <br /> _ / 2)3V 6 6C1-66 7 <br /> Sanitary Permit Application State Transaction Number <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 Servies. Personal information you provide may be used for secondary n <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. PAR KE.R PASS <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> \ J NIJSOR aids KI2_.( LLC (c) ANABLAKic 09ii— 193 - 00(9'1 .- o <br /> Property Owner's Mailing Address Property Location <br /> 4(40r1 OAK SPR iL is C1RCLE Govt.Lot p <br /> City,State Zip Code Phone Number NE %, $W Vs, Section ( <br /> DeroeEsr , Gtr I 5353-5 2 T 9 N; R II E <br /> II.Type of Building(check all that apply) Lot# f J <br /> NI or 2 Family Dwelling—Nut bet of Ikedrq¢ths t {I ! f i r,', r Subdivision Name t <br /> ,f' ' Block# PAR KE- S PLACE. <br /> ❑Public/Commercial—Desenb Use ❑City of <br /> � _ <br /> NOV 2 5 2014 <br /> 1 ice' CSM Number <br /> e <br /> ['Village of <br /> State Owned—Describe Us' <br /> ®Town of 13R t$Ti;1 L <br /> t' ,', ,n its <br /> III.Type of Permit: (Check only forte box on line A. Complete lure B if applicable) <br /> A' ®New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ['Other Modification to Existing System(explain) <br /> B. [1]Permit Renewal ❑Permit Revision [(Change of Plumber []Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> INNon-Pressurized In-Ground ['Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) . Dispersal Area Proposed(sf) System Elevation ! o,Y ' <br /> CA 0 0 c7/ /5— A-5--- [y T�_7/ 9Zo 9'4 0,,704.7 <br /> VI.Tank Info ' Capacity in Total #of Manufacturer u <br /> Gallons Gallons Units il g U°1 <br /> New Tanks Existing Tanks 4 o 2 P 0 5 <br /> a.U in , rn ii 0 C <br /> Septioeirftellttng Tank ` ' M V.A D E >< <br /> � <br /> Dosing Chamber (050 — 1050 . M i:A 4.e /1 <br /> VII.Responsibility Statement- 1,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 __, _ 40.. 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 nt ature <br /> _Approved ❑Disapproved g/ <br /> D Owner Given Reason for Denial $ 13!1 11--2.6-20/y _ c <br /> DC.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R. 1 1/1 1) <br />