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F- 't Safety and Buildings Division Dane &lb <br /> • : )1$ • - 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Nurnbes(to be frilled in by Co.) <br /> ▪ �: PS Madison,WI 53707-7162 <br /> 13-2( s— cx3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wits.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 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 q <br /> purposes in accordance with the Privacy Law,s.15-04(1)(m),Stilts_ /'-!'1-4- U/u, Po 1 i o nai' IL <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> ( do A-L 2 0505- 3 12- 2U4(0- G <br /> Property Owner's Mailing Address Property Location <br /> 029 3 S S. As , 1-4-t%.-, t-+' Y (.i?d l i 2_t 17 coot.Lot <br /> City,State Zip Code Phone Number <br /> M KO i SUN) W l 53'? l( <br /> NV/ '/; M '/. section 31 <br /> IL Type of Building(check all that apply) 4 Lot y <br /> T b N; R 2, E <br /> riIor2Fami ly Dwelling—Number ofBedrooms 4 1 C Subdivision Name <br /> Block g Atit.TV(.Ml IJ 'Po Nt D <br /> ❑Public/Comm ercial—Describe Use <br /> ❑State Owned—Describe Use <br /> RECEIVED CSM Number 0V;�ageof <br /> APR 1310 Town of SPtztII(nFtIE.I..b <br /> III.Type of Permit. (Check only one box on line A. Complete line B if applicable) <br /> ' <br /> Public N DG k ®New System ❑Rep�� <br /> olding Tank Replacement Only QOther Modification to Existing System(explain) <br /> List <br /> B. ❑Permit Renewal El Permit Permit Revision ❑ of Plumber QPe suit Transfer to New Previous PermitNunrber and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 'INNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment 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 /> (9 O o - 47 /Soo /s 0 o W. '93,5' 9�.ys' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units _0 o 6 v <br /> New Tanks EeatingTanta d g. o S <' ' c c <br /> p�/ �r , q� 2ci v'5 , in n.O C <br /> Septic or Holding Tank l a5 Co la d to �- mil,EA'0 E / <br /> Dosing Chamber - - - - <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Phanber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz 4_.(_, 1..9 , 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> �V,IIII.County/Department Use Only <br /> �T.Approved Disapproved Permit Fee Date Issued lss tSignature(6.0,4--e- <br /> IX. <br /> ❑Owner Given Reason for Denial 4-/i-ZS' �i <br /> Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on papa-not less than S vs x 11 inches in sir <br /> 7 <br /> SBD-6398(R.11/11) <br />