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---; <br /> :• 1%7 ...- <br /> tY <br /> Da-i'l <br /> Safety and Buildings Division • C. <br /> 1-A ) <br /> 7 201 W.Washington Ave.. P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' S • I:=1 <br /> -. -\ Pe • . . Madison,WI 53707-7162 <br /> t 7. <br /> S <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 arc 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 in accordance with the Privacy Law,s.15.04(1)(m),Stats. a 1(20//-C-"ii-C., 20a-ci---- <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ..,t s-./.1, ._S' 0 A.,2_i-v) .-.----(E , ‘ ), , \ -r 1 <br /> :-.), E1`-\ O57_ C)1(/ --'9.75-0 —O <br /> Property Owner's Mailing Address Property Location <br /> /9,3 /2‘.....ii Govt.Lot <br /> City,State Zi,wCadeN Phone Number Sr 1/4,-5. - 1/4, Section 7 <br /> ,J4--/-t, /-74.1-,- L('/ . ..,"s3 s-V2.. 1/3F— W 3 5-- <br /> T 5 N; R 7 E <br /> IL Type of Building(check all that apply) _t..7L. Lot# <br /> Xor 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> - Block 4 <br /> OPublic/Commercial-Describe Use <br /> 0 City of <br /> OState Owned-Describe Use CSM Number 0 Village of <br /> /3 e 9 2-- 0 Town of if'""fo5C.... <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System 0 Replacement System DTreatment/Holding Tank Replacement Only <br /> X DOther Modification to Existing System(explain) <br /> Permit Number and Date Issued <br /> B. D Permit Renewal 0 Permit Revision ['Change of Plumber ['Permit Transfer to New List Previous <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressarized In-Ground ['Pressurized In-Ground ['At-Grade RvIound>24 in.of suitable soil 1=1Mound<24 in.of suitable soil <br /> 0 Holding Tank Either Dispersal Component(explain) laretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> '6 b . 6 /6 0 0 <br /> VL Tank Info Capacity in Total #of - Manufacturer <br /> Gallons Gallons Units 13 1 'LI"' - 4:1 <br /> New Tanks Existing Tanks 46 g 2 Ti , i `33 <br /> tn.) i7i v, co 14 CD a <br /> -Septic or Holding Tank <br /> _ - <br /> Dosing Chamber 6 5-..- 650 / <br /> VIL 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 , ,4._..,r___ e4_). -7,7-1S 220165 608-831-8103 <br /> um <br /> Plumber's Address(Street,City,State,Zip Code) I __ ____, <br /> 6813 County Highway K,Waunakee WI 53597 ------ <br /> ...-------- <br /> - - <br /> V .County/Department Use Only <br /> it <br /> Approved ' 0 Disapproved <br /> 0 Owner Given Reason for Denial Permit Fee Date Issued <br /> $\f2A ■ Se-IIS Issuing Age -":•lature <br /> -.... <br /> ....0 / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ------ <br /> _,---- <br /> Attach to 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 />