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..^"rspnrtii',. County <br /> Safety and Buildings Division Dane <br /> j D S ..'�:i 201 W.Washington Ave.,P.O.Box 7162 Sanitary s 9 Permit Number(to be filled in by Co.) <br /> ,,�, P „ Madison,WI 53707-7162 <br /> \ ..s : f3 26 (5=GDo (Z._.. <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 134j LA U R E 1.. L A N i <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> MKE-c- V14 MADtsoN LLC 0r108 - 2.0 3- Co144-4 <br /> Property Owner's Mailing Address Property Location <br /> ( C 1 So utTh-1 TUW t E DRZ‘v E Govt.Lot <br /> City,State Zip Code Phone Number 9 E tIA S W r/4, Section 20 <br /> Mt o1Soi1 lkil 3'713 T 7 N; R 8 E <br /> II.Type of Building(check all that apply) ( ' Lot# <br /> ®1 or 2 Family Dwelling-Number of Bedrooms_ t 5 1 041 Subdivision Name <br /> Block# S P RucE w <br /> ❑Public/Commerciat-Describe Use <br /> ❑City of <br /> State Owned-Describe Use CSM Number ❑Village of <br /> J Town of \A I.DO e,0.-ro i!J <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber [hermit 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 /> ®Non-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(pd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation, i 8 3 <br /> '150 4 y /S-7-C /gq6 gs.9 99. 9$.s 9 . <br /> VI.Tank Info Capacity in Total #of Manufacturer & <br /> Gallons Gallons Units _ <br /> g u U <br /> Now Tanks Existing Tanks aq °•3 I 1 <br /> w U it .n rn iz a 0. <br /> Septic or Holding T a n k 1 1 _5v, U.CEO a Wix o s / <br /> Dosing Chamber Boa V 00 I M i✓Io€ X <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation o 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. ""y,—, 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 /> ❑Disapproved Permit Fee Date Issued Issuing Age = ure <br /> )(Approved a �{3l ����5 • - <br /> ❑Owner Given Reason for Denial ,�, <br /> IX.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.11/11) <br />