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Safety and Buildings Division County <br /> ` 201 W.Washington Ave.,P.O.Box 7162 Dane <br /> lr;�It t•,S a� Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ` . 1 .3 -2015—nO2_3(4 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),W is.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application fours for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(IXm),Stats. Lot 15,Bristol Gardens <br /> L petty O lion Information-Pka gtAlt infaU <br /> Property Owner's Name Parcel# <br /> Andrew&Kelsey Eye (current owner is Don Tierney) 012.0911-303.6315-0 <br /> Property Owner's Mailing Addr Property Location <br /> 5421 Day Tripper Dr. <br /> Govt.Lot <br /> City,State Zi a Phone Number SE Y.,SW '''A,Section 30 <br /> Madison,WI 718 715-308-9657 (circle one) <br /> IL Type of Building(check all that apply Lot 4 T 9 N; R 1! <br /> 121 or 2 Family Dwelling-Number of ms 411 15 Subdivision Name <br /> Bristol Gardens <br /> Block 4 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Q Town of Bristol <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. LA New System ❑Replacement ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> System <br /> B. ❑Permit ❑Permit Revision ❑Change of ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> tii Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 600 .4 1500 1500 95.9 <br /> VI.Tank Info Capacity in Total 4 of Manufacturer Material <br /> Gallons Gallons Units <br /> New Tanks Dusting Tonics <br /> Septic or Holding Tank 1286 1286 Meade Prefab Concrete <br /> Dosing Chamber 650 650 1 Meade Prefab Concrete <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation oft POWTS shown on the attacked plans. <br /> Plumber's Name(Print) Plumber's S' MP/MPRS Number Business Phone Number <br /> Andrew W.Meiaholz CtJ_' 220165 605-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 C111 K,Waunakee,WI 53597 <br /> VIII.County/Department Use Only .r. / <br /> _Approved _Disapproved Permit Fee Date,ssued I - , <br /> t —Owner Given Reason for Denial S 71 a' - 4S �_t ���- <br /> IX.Conditions of ApprovalReasons for Disapproval J <br /> Attach to complete plans for the system and submit to the Comity Daly on paper not Ins than h 1/11 11 inches is sae <br /> SBD-6398(R 01/07)Valid thru 01/09 <br />