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wv.mcr riv , County <br /> ��%ip �\,r Safety and Buildings Division Dane <br /> s i S �,i 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filed in by Co.) <br /> ;,1 R S <br /> r Madison,WI 53707-7162 <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 /� Q <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm),Stets. PAR.K — <br /> I. Application Information—Please Print All Information pi,AC__i_ <br /> Property Owner's Name Parcel# <br /> DAv'E- Art'li] L, 1—I-e-R7..0 67 09 II — (g — 013 -0 <br /> Property Owner's Mailing Address Property Location <br /> er <br /> 6 009 g R t i412 .L..PrN E Govt.Lot <br /> City,State Zip Code Phone Number K1.5 y S W r/� Section 1 9 <br /> Su,N Prz,P►kit a 1&11 -90 <br /> T ,1 N; R I I e <br /> II.Type of Building(check all that apply) Lot# <br /> I511 or 2 Family Dwelling—Number of Bedrooms 4 I-6 Subdivision Name <br /> _ Block# <br /> ❑Public/Commereial—Describe Use <br /> ❑City of <br /> ['State Owned—Describe Use CSM Number 0 Village of <br /> ®Town of BF&LS'TC■L <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. MNew System y [I]Replacement System ❑TrcatmentlHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Penn it Renewal El Permit Revision El Change of Plumber List Previous Permit Number and Date Issued <br /> QPermit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all th pp1 -- '----..1 <br /> ❑Non-Pressurized In-Ground ['Pressurized In-Ground ❑At- de Mound>24 in.of suitable soil [Wound<24 in.of suitable soil <br /> IDHolding Tank 1 N Other Dispersal Component(explain) retreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dis Area Proposed(sf) System Elevation <br /> Or I l23C>f`� I ( ,� I <br /> VI.Tank Info Capacity in Total #of banufactl>rer , <br /> Gallons Gallons Units *E c y� <br /> New Tanks Existing Tanks a o u 2 .� d 1 <br /> v U in y w a P., <br /> t tptic or,I�okling Tank I r► Q/. OA to a M EA D E /< <br /> Dosing Chamber (0 5 Q li5 0 I M Pc D X <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) 1 P bar's Signature M MP/MPRS Number Business Phone umber <br /> Gary Meinholz �, �� '"V• I 222318 608-831-81NO3 <br /> Plumber's Address(Street,City,State,Zip Code) _.` <br /> 6813 County Highway K,Waunakee WI 53597 �r \\ <br /> VIII.County/Department Use Only <br /> . pproved ❑Disapproved it Fee Da /Issued ' A i <br /> jY/ `�` ❑Owner Given Reason for Deni r,24(.9 L ti <br /> IX.Conditions of Approval/Reasons for Disapproval l <br /> ■ <br /> Attach t o complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in size <br /> SBD-6398(R. 11/11) <br />