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x;�yaa nri\.,. County <br /> �, N Safety anf D Dane v <br /> 2 <br /> =': 0 201 W.Washin P O Sanitary Permit Number(to be filled in by Co.) <br /> I� I <br /> P � Madison, <br /> ‘i- �\ ._-S. ice/ <br /> MAR -9 205 13 -20 ( 5��-OOO 7 <br /> Sanitary Permit Applicati n Publliric Health M1DCQQ''tt}} State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Projec 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(1)(m),Stats. PA 214. R_ PAS S <br /> L Application Information—Please Pr All Information C <br /> Property Owner's Name (I e1I\.( t7VJ ki�12+.�a Parcel# <br /> I N 020 R. QuAt2rz y 11C [ADAM c A S y N I E M U11-I) 0911 - 19 3 002-3-0 <br /> Property Owner's Mailing Address Property Location <br /> 4(1017 OAK SPKINJGLS ClItC(--E Govt.Lot <br /> City,State ^ Zip Code Phone Number <br /> D1:�G12ESY ,� ( p N ''/4, Ci '/4, Section I9 <br /> 5 3E 3 2, T 9 N; R I E <br /> II.Type of Building(check all that apply) Lot# <br /> l'ill or 2 Family Dwelling—Number of Bedrooms 'q 3 t/ Subdivision Name <br /> Block# PAR k1=12. PLACE <br /> f LACE <br /> [(Public/Commercial—Describe Use <br /> El City of <br /> ['State Owned—Describe Use CSM Number 0 Village of <br /> 12 Town of B k t STU L <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. El 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 /> ❑Non-Pressurized In-Ground ❑ <br /> -Ground ❑Pressurized In-Ground At-Grade Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> n- <br /> ❑Holding Tank t a rther Dispersal Component(explain) treatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sp Dispersal Area Proposed(si) System Elevation <br /> Co 00 /bob ✓/c7-00 5Er Ar-1- �l <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a a <br /> New Tanks Existing Tanks d g Y u E .n 3 2 <br /> 0 <br /> 0.0 'EA ti w6 a <br /> Septic or Holding Tank I h Pj/ _ PR/ t A EA-D E X <br /> Dosing Chamber (SCE , 5 I• 1h/�ieL o �/1 <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/MPRS Number Business Phone Number <br /> Andrew W Meinholz —e____ Gtr. 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VI ,County/Department Use Only <br /> Permit Fee d Date Issued Issuin:/•gent Si:4 :I ., — r <br /> Approved ❑Disapproved d.,�— ;�� <br /> ❑Owner Given Reason for Denial s12116. /I log ,�+A _���- <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 tax II inches in size <br /> SBD-6398(R. 11/11) <br />