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` yAlt <br /> ` riu_ti County <br /> Safety and Buildings Division Dane Mi <br /> 0 ` ,.;: 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �\a D S 1-%! :,' Madison,WI 53707-7162 <br /> l 3 - 20 ∎ 5-- ooa� 6 <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 accordance the Privacy Law, t , <br /> 1. Applic ation Info rmation-Please Pri nt All I nforma tio n RECEIVED S l L VEizz' ' ROAD <br /> Property Owner's Name Parcel# <br /> M12 EC Vi-t MADI oNL t-C-C MAR -6 2015 090S - Z03- a089 - 0 <br /> Property Owner's Mailing Address Property Location <br /> (0 Sd I SUU-7-b-1 -rov N E D RAV 1. Public Health MDC Govt.Lot <br /> City,State Zip Code �{rPhnemNeeumber Health r <br /> `„S�d� I 5 E /n, S 1t(/ 1/4, Section ao <br /> 11.Type of Building(check all that apply) / Lot# T r] N; R G E <br /> ®1 or2 Family Dwelling-Number ofr.. i'■ins 9 Subdivision Name <br /> Block# S p K uck.- (--61-401/4&) <br /> ❑Public/Commercial-Describe Use <br /> El City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> M Town of 1141 DOLE—TON <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal El Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> 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 [It-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/Treatm ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> r750 0 ,y 1a?S /8?tO 97, 5 <br /> VI.Tank Info Capacity in Total #of Menu acturer <br /> Gallons Gallons Units f o v u <br /> New Tanks Existing Tanks ' C ,, 11 i 1 <br /> 0 <br /> a U rn H v, w c7 0. <br /> Septic or Holding Tank a CO s n, '(0 J O .. 't p O% X <br /> Dosing Chamber 800 O I I t AD X <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' Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz AA... w. - 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> County/Department Use Only <br /> i) ir <br /> Approved ❑Disapproved Permit Fee bf Date Issued Issuing Agent•gna <br /> L() 1 3-�-�s dry" <br /> ❑Owner Given Reason for Denial /^ �- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> it <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 />