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County -� <br /> Safety and Buildings Division Dane n l i <br /> f/ h _-: B S _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co_) <br /> = P S Madison,WI 53707-7162 <br /> 1 3 205 Oo\2.3 <br /> Sanitary Permit Application State TumaaaionNumber <br /> In accordance with SPS 3Si2I(2),Wis.Adm.Code:submission of this form to the appropriate governmental mM <br /> is required prior to obtaining a sanitary permit.Nate Application forms for state-owned POWTS are submitted to Project Address(if different than mailing ) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 1� <br /> purposes in accordance with the Privacy Law,s.I5.04(IXm),Stets M o Nt(G U,}r Su(.1 V Ri v E <br /> L Application lication Information-Please Print All Information <br /> Prop Owner's Name <br /> PALA trsCN) DEv 0PMEt4.r L-LC 911 - t9Z- 0579 -0 <br /> Property Owner's Mailing Address Property Location <br /> 4(007 OAK S PR.!10(1)S CK CLE <br /> (lost Lot <br /> City,State Zip Cade Ph rte Number d N r ih. '1,W nh. Section 19 <br /> D E 2ESr \kJ I 3 <br /> II.Type of Building(check all that apply) lot= T � N: R �� E 4 I NauuK <br /> [1 or 2 Family Dwelling-Number of Bedrooms <br /> Blocky 4-'' Q)AI) t5rATE5 <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> OState Owned-Describe Use CSM Number ['Vi llage of <br /> ®Town of g 12.1 s-rn l <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. ®New System D Replacement System DTreatment/1-lolding Tank Replacement Only (DOther Modification to Existing System(explain) <br /> �-I_ M <br /> B. D Permit Renewal D Permit Revision [(Change of Plumber []Permit Transfer to New l'm cuss Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> iNon-Pressurized In-Ground []Pressurized In-Ground -Grade ❑Mound?24 in.o7fsuitable soil Dr Mou d<24 in.of suitable soil <br /> Holding Tank []Other Dispersal Component(explain) LDPtetreammnt Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design SaTApplication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Arca Proposed(sI) System Elevation <br /> Ce 0 0 1/ (p �o /O-. v s,„1 S- ,za—„ <br /> VI.Tank Info Capacity in Total °=of Manufacturer <br /> Gallons Gallons Unix £ tj -° <br /> Nom Tanks aistire Tanks v 5 it m 'i <br /> Septic or Holding Toni: '.2-..i) _ 12X Y M gi4-0 C '1 +1-• <br /> . <br /> Dosing chamber t9 5O L60 ) ►•tit-a o e .> .1 I <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 MPMIPRS Number Business Phone Number <br /> Andrew W Meinholz --L C-u 220165 608-831-8103 <br /> Plumber's Address(Street City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VII.County/Department Use Only <br /> Permit Fee Date Issued I "•tom' <br /> Approved 0 Disapproved S t t _ <br /> ❑owner Given Reason for Denial 11.47 l .� r 5/ ," � y <br /> IX.Conditions of ApprovalReasons for Disapproval <br /> Y ( f <br /> t <br /> Attach to complete plans for the system and submit to the County only on paper not less than 3 1/2 s is inches in we <br /> SB D-6398(8 11/11) <br />