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1- :;.‘,, County <br /> Safety and Buildings Division Dane RD Ala. <br /> t 0 S P I't 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI EIVED <br /> 0-zuu= -c 0 <br /> Sanitary Permit Application MAR 2 6 2015 State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropri 1 1 i't <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-own . •`lr : ,r �t «i A. �roject Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide -t f,. , : T <br /> purposes in accordance with the Privacy Law,s.15.04(l Xm),Stats. e LCo I A i )1 l\.i - <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Cc.N£to .04/.0t/z- <br /> (tea ��� Parcel# <br /> AA*/t7 s ,// jl4o,n.�s Goft6- 0-7 OS— 301 - (917?- 0 <br /> Property Owner's Mailing Address Property Location <br /> LI'7 03 SUI\iSET" R 1 o& DR IV. _ Govt.Lot <br /> City,State Zip Code Phone Number S E �'A,f((_ rA, Section 30 <br /> M IDD'i-a-rOly `/3I / 3S Co a T r' N; R 8 E <br /> II.Type of Building(check all that apply) Lot# <br /> 1 Subdivision Name <br /> 1 or 2 Family Dwelling-Number of Bedrooms L/ I r J <br /> Block# C 1-I V Rey v,l00 lc> .)KEsT <br /> QPublic/Commercial-Describe Use 0 City of <br /> CSM Number ❑Village of <br /> ['State Owned-Describe Use <br /> ID Town of (VII 410 LETO I-4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. SNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only QOther Modification to Existing System(explain) <br /> B. ❑Change of Plumber ['Permit Transfer to New List Previous Permit Number and Date Issued <br /> a <br /> ❑Permit Renewal ❑Permit Revision <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> N:'Non-Pressurized El <br /> Other and Pressurized In-Ground ['At-Grade OMound>24 in.of suitable soil OMound<24 in.of suitable soil <br /> ❑Holding Tank LJOther Dispersal Component(explain) Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) I Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation► <br /> / , C/ I /s'`'� I /,5/7,_ *�89i $8,' Y7 <br /> (O G <br /> VI.Tank Info Capacity in Total #of Manufacturer ,2 c <br /> Gallons Gallons Units ..gg U° <br /> '^ <br /> New Tanks Existing Tanks c 33 b' 8 <br /> a,cg m . Cl) wc7 a <br /> Septic o.Helding Tank /0).' S G _ -(15G <=2 M E.A.D i✓ <br /> Dosing Chamber G 6-..? .•_- &-5-42 1 0 e AD e_ <br /> Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown the attached plans. <br /> Phone Number <br /> Plumber's Name(Print) Plumber's Signature I <br /> Andrew W Meinholz I ._. 4.-e_.- G.), 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 /> IR Permit Fee Date Issued I <-,-Issuing t Si pproved ❑Disapproved $ 3---30- `. *47 <br /> El Owner Given Reason for Denial i <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 sin x 11 inches in size <br /> SBD-6398(R.11/11) <br />