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County <br /> • s Safety and Buildings Division Dane <br /> :-• <br /> .`,Ij s _ 201 W.Washington Ave-,P.O.Sett 7162 Sanitmr payak Number{to be fiUed'm by co_ <br /> ,_ PS Madison,WI 53707-7162 <br /> Setae Transaction Number Permit Application <br /> In accordance with SPS 35311(2),Weis.Adm.Code submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary pemic Note Application forms for state-owned POINTS are submitted to Project Address(if diferrrrt than mailing address) <br /> the Department of Safety and Professional Servies_Personal information you provide may be used fors <br /> purposes in accordance with the Privacy Law,s.15-04(I)(m),Stets PARKER PASS <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel <br /> 1r1/41 INO50K QuAgS..Nt 11-C z--;0911- 193- 0059- 0 <br /> Property Owner's Mailing Address Propene Location <br /> 4(0o11 OAK SPR►4.G1s CtRGLE IGovt.Lot <br /> City,State /O <br /> I Zip Codc (Phnrmc A'umber ✓�E % S W =/Section 1 <br /> DE. .sr V�11 j 53532 1 <br /> ''i T 9 N: R 11 E <br /> IL Type of Building(cheat all that apply,) t 1-ot= 1 <br /> adI or 2 Family Dwelling-Number of Bedrooms 4 „- Subthvision Nance <br /> Block vPAsu j2 t S PLACE If <br /> ❑Public/Cornmereial-Describe Use RECEIVE °City of <br /> QState Owned-Describe Use � M Number Q Village of <br /> JUN 1 5[VU Il'Tommof BRISTOL. <br /> III-Type of Permit (Check only one boc h.,..���,�.{�.�_e�line II if applicable) I� <br /> A" New System 1❑Replicement-gittirling Tank Replacement Only (Other Modification to Existing System(=plain) <br /> A' 1 I `+ <br /> 1 r D <br /> B. ❑Permit Renewal El Permit Revision I[IChanse of Plumber I Jramit Transfer to New last Previous Permit Number and Dale Issued <br /> Bt fore Expiration I ( Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground QPressurized In-Ground D ec At-Girade ,Maned>24 m of suitable soul ❑Maud<24 is of suitable soil <br /> El Holding Tank DOther Dispersal Component(=plain) OPretreatnent Device(=plain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) ' Design Soil Application Rate(gpdst) I Disp l Required(st) Area Proposed(sf) System Elevation <br /> (a OO `7- t/a ,-"„"c...,p t/ f/41,c7 Se--r- A1' Sire. <br /> VI_Tank Info Capacity in I Taal x of Manufacturer 2 I ^- <br /> Gallons Cations Units = a _ - <br /> u,:Tanks 1 Esamin_Tanks I y 1 ° - _% <br /> Holding Tank t I =u I r so I <br /> cs.pr 1 A8/, I I Dt A- 114e.ADe. I .X I I <br /> Dsiag Chamber I (,o 1 I( 5o 11 1 ►.4eADE I >< I 1 1 <br /> VII.Responsibility Statement-I,the tmdetsigaed,assume respoasibibty for instal/alien of the POWTS shown on me attacbed pleas <br /> Plumber's Name(Print) I Plumbers Signature } MP/MPRSNumber Business Phone Number <br /> Andrew W Meinholz i 64,..)L _ -1--+� 2201 68 831 8103 <br /> Plumbers Address(Suede,City,State:Zip Code) jv) <br /> 6813 County Highway K,Waunakee WI 53597 / <br /> VIII.County/Department Use Only ' - <br /> P w it Fee _ Doc Issu�e7d i I �_� <br /> PPtoved 0 Disapproved S y `4 W. 10 l//5 -' <br /> ❑Duna Given Reason for Denial ( �f - `'-�, <br /> IX.Conditions of Approval/Reasons for Disapproval t// <br /> A <br /> . <br /> Attach to complete plass for the system and salmis to the County only on paper not less than 8 ra a 1I inches in she <br /> S130-6398(R_11/11) <br />