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County
<br /> Safety-antr swittkpo Division. '::3 ' i Dane
<br /> 201 W.4shingtorDAye.,LIP.0.1knaiel2
<br /> Sititary Permit Number(to be filled in by Co.) —
<br /> iSOrli WI 53707=7162
<br /> lf-1 I 7 (3 --„ 6S- 0 6 I )
<br /> ill cl.OZ 9 Z AV Ni r. 1'
<br /> I f ,
<br /> Sanitary Permit Apphe Llon ,■..State Transaction Member
<br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this ti.; . .,.... • n ',
<br /> is required prior to obtaining a sanitary permit Note:Application forms e No to.`linject Address(if different than mailing address)
<br /> the Department of Safety and Professional Servies. Personal information Yore z
<br /> ay.be for'Sencidary—
<br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stets.
<br /> L Application Information-Please Print All Information ' (01 C4. k.v.- A a
<br /> 1 i A.
<br /> Property Owner's Name Parcel II
<br /> Dar-e Co, A E A, kVSLIA,A 1 CTCorG i-e 00/0711- 1:41"'85440''%
<br /> Property Owner's Mailing Address Property Location
<br /> .tet /q■GA■e■ L.‘4V4,e,v- 4:.,5 Zr RA vok kAA 114 Govt.Lot
<br /> City,State Zip Code Phone Number
<br /> (/'" %, J'..) Ye,Section 0
<br /> AA6AtSuh '''''.1 S3701
<br /> T 7 N; R 1
<br /> IL Type of Building(check all that apply) Lot 4
<br /> Eh or 2 Family Dwelling-Number of Bedrooms Subdivision Name
<br /> tea,,„,,, r-,-:solo,.4..er, Block# —
<br /> IRIPubliaCommercial-Describe Use A■Os t4.41, Ck.ead$a
<br /> El City of
<br /> 0 Village of
<br /> 0 State Owned-Describe Use CSM Number
<br /> IR:1 Town of C...t1/44s.e. r ,Q.
<br /> III.Type of Permit: (Check only one box on line A.Complete line B if applicable)
<br /> A. ri
<br /> New System gReplacement System 0 Treatment/Holding Tank Replacement• Other Modification to Existing System(am'
<br /> B. 0 Permit Renewed 0 Permit Revision 0 Change of PI bcr D, itTransfer . _ List Previous Permit Amber and Date Issuej.1../
<br /> Before Expiration Owner 107 S(14-t 11-17--letc(1
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> MNon-Presswized In-Ground I:Pressurized In-Ground 0At-Grade :Wound>24 in.of suitable soil :Wound<24 in.of suitable soil
<br /> 0Holding Tank 00ther Dispersal Component(explain) anstratunait Device(explain)
<br /> V.Dispersal/Treatment Area Information:
<br /> Flow(gpd) Design SgirApplication Rate(gpdsf) Dispersal Area ReVisf) Dispersal Area Proposed(st) System Elevation
<br /> 7.6-1-S 7,S t5 it.cob Ia.C. , iq:L.
<br /> VI.Tank Info Capacity in 'Total #of Manufacturer
<br /> Gallons Gallons Units 2 t.° o
<br /> 1 E t.)l'-'• ., .1-...”
<br /> New Teaks Existing Tanks T, g 2 "2 ,gli id
<br /> 0,0 sell VI u.t:7 c.
<br /> Septic 0.411ohlios Tank /C.100 ...... .C30 I C res3r A
<br /> Dosing Chamber
<br /> Obo _ v X, -
<br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWYS shown on the attached plans.
<br /> Plumber's Name(Print) ber's Signaturem,v MP/MPRS Number Business Phone Number
<br /> Gary A Meinholz 222318 608-831-8103
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 6813 County Highway K,Waunakee WI 53597
<br /> County/Department Use Only
<br /> Permit Fee opf Date Issued Issuing Agent SignatureAV
<br /> ZIALpproved 0 Disapproved .-
<br /> 0 Owner Given Reason for Denial $ 4."
<br /> IX.Conditions of Approval/Reasons for Disapproval Te/1(
<br /> coAotTcrofe,- -ris eicu-ritar. PAA"rilfP firrfA,
<br /> 7_ tqq3 Ai Per, rAY(771/CY i%441(7.----1)4fir 17—'°7?e/1(77143416:.
<br /> Misch to complete pleas for the systole and submit to the Cotten,°sly ow paper sot less than 81/2 x 11 lathes m size
<br /> SBD-6398(R.11/11)
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