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County <br /> Safety and Buildings Division Dane RIV <br /> —`B S , _ No 201 W.Washington Ave.,P.O_Box 71662 Sanitary Peamit Number(to be filled in by Co.) <br /> ,.;, �, ,SCA N ED Madii • ' 11w 5 n, <br /> i. ; 13-26(5 00 (5t <br /> -�A'�� + -'ate Transaction Number <br /> Sanitary Permit App 44;on . 1 1 2015 <br /> In accordance with SPS 3f3.21(2),lilts Adm_Code,submission of this N o'the appropriate governmental uri <br /> is required prior to obtaining a sanitary permit Note:Application forms cur state awned POWTS are submitted o Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies_ Personal information you prnrtie m:,. e n f^r seconder <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. Pub::., ,,_....t; `i v 27 9 r7 L A L- � hO.41) <br /> 1. Application Information-Please Print All Information Fr=. '- --- "H`n <br /> Property Owner's Name. 1 if <br /> T1IMUTHy 1Qr�+1.e61J Cu2QAN (c/o R�ND1 i�-Expr��a&,I 0- 012- 9000-3 <br /> Property Owner's Mailing Address Property Location <br /> 346 W WA5H i ni G-roN A v E-N(A e SUITE 30 I Govt Lot 7 <br /> State Zip Codc Phone Number S A 1/4, 14 tAf r/,, Section <br /> IA f -Ul fermi VJ I 53703 T (p N; R IO E <br /> IL Type of Building(check all that apply) Lot <br /> erf.1 or 2 Family Dwelling-Number of Bedrooms .3 Subdivision Name <br /> Block# .Ere-5 Am, BOLOS <br /> ['Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ['State Owned-Describe Use <br /> Town of p(.{.!V N <br /> III.Type of Permit_ (Check only one box on line A. Complete line B if applicable) <br /> A. ['New System gReplacement System ['Treatment/Hold--mg Tank Replacement Only []Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. []Permit Renewal ❑Permit Revision ['Change of Plumber []Permit Transfer to New <br /> Before Expiration Owner <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground ['Pressurized In-Ground at-Grade OMound>24 in of suitable soil ['Mound<24 in.of suitable soil <br /> ['Holding Tank ['Other Dispersal Component(explain) DProtreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Area Proposed( System Elevation <br /> Des Flow(gpd) I Design Soil Application Rate(ggpdst) I Dispersal Area R (st) I Dispersal � a 2 5 <br /> 0 !! 7 8,3 , ct 7• <br /> VI_Tank Info Capacity Gallons Total of Manufacturer 0 o v o 0 <br /> Gallons Units <br /> New Tanta Existing Tads COG l �i /� i U rn y r� ti O C. <br /> Septic aa45atdi.gTank 1 COO �= II COG 2 ■I`^ E <br /> Dosing Chamber l Cvg G �— o l M E-AU _ <br /> VI.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 I MP/MPRS Number Business Phone Number <br /> Andrew W Meinhoiz I f --a%i w, l > 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 /> Permit Fee Date Issued Issuing Anent Si <br /> )(Approved ❑Disapproved S 4-73/ I 6--(2.-208-1 / <br /> ❑Owner Given Reason for Denial C•r <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 01--D fro- m . /BFI Fl-D To ,SIBJ4/�p F6_ <br /> —b iv t./ F6 A0/447/4 Piv fmf7 ". A .1-CA-r7 . S--FEE---r f4,., escr7:04. `VEIL, <br /> Attach to complete plans for the system and submit to the County only on papa-not less than 8 tax 11 inches in size <br /> SBD-6398(R-11/11) <br />