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County ��,, AA 1 <br /> �,.;:.F,:r,, Dane 't G) <br /> Safety and Buildings Division <br /> z U ` 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be lied in by Co.) <br /> S • i- Madison,WI 53707-7162 <br /> P <br /> S 1 20i`3 cri11 <br /> "" ' 'State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Mm.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 Si LU,- J ea" 'KO 0 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> r Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> M 12�C '+Siv <br /> O U , <br /> 2C) - G2-32-0 <br /> Property Owner's Mailing Address <br /> Property Location <br /> 4-98 o( J 012T,H '1V ti ki E D .\V Govt.Lot <br /> City,State Zip Code Phone Number <br /> SE %.„5__W__'4, Section_f 6_ <br /> MPDI5GN bvl 53 '?I3 T LN; R E <br /> - <br /> U.Type of Building(check all that apply) Lot# <br /> Subdivision Maine <br /> �l or 2 Family Dwelling-Number of Bedrooms I' 5 P Name VI) <br /> Block# _ <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑Stale Owned-Describe Use ©Town of LA j: Ult.. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A cation to Existing System(explain) <br /> 'New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification <br /> - List Previous Permit Number and Date Issued <br /> B. ❑PermitRenewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.T .e of POWTS S stem/Com I onent/Device: Check all that a, ,1 <br /> &Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑OUer Dispersal Component(explain) Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Dispersal Area Required s Dispersal Area Proposed(st) System Elevation / i <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) pe q (f) � Pi-3' ��/,V 63' <br /> `i50 �-/ /0 7S /87" <br /> VI.Tank Info Capacity in Total #of Manufacturer v u <br /> Gallons Gallons Units d <br /> New Tanks Existing Tanks aa G <br /> n-U N y <br /> Septic or Holding Tank 50 1117a .2. V # MI <br /> Dosing Chamber ;0 Ir411,1 I <br /> u <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> MP/ <br /> MPRS Number Business Phone Number <br /> Plumber's Name(Print) Plumber's Signature 60$-831-8103 <br /> Andrew W Meinholz /� � — ,Lti _ <br /> 220165 <br /> Plumber's Address(Street,City,State,Zip Code) `� <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VI .Cosa /De ailment Use Only <br /> Permit Fee Date Issued issuing Agent <br /> Approved ❑Disapproved $ .,❑Owner Given Reason for Denial ` l — Sr S <br /> At <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 11 rn x 11 inches in size <br />