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-:a:ar..._ ( County PIG and Buildings Division I Dane <br /> 13 S 201 W.Washington Ave_.P.O.Box 7162 Sanitary Permit Number(to be filled in by Co_) <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),this_Mm_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 info'minion you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s_15.04(1)(m),Stets_ W 0 DA �d�D <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name paw <br /> T1-1-. .ESA eeu-g.S a/ J 1,j =,,,,� I °4°23-303- 0359 - 0 <br /> Propertyy Owner's Mailing Address Property Location <br /> 1 0 R- Y Pi ki€ COtAKT Govt.Lot <br /> City,State ( zip Code ' Phone Number <br /> '�.A'D>�GtJ <br /> N Yi, Sl�l r/.: Section .�D <br /> 1 53717 i T .7 N: R 5 E <br /> IL Type of Building(check all that apply) Lot <br /> ig Ior2 Family Dwelling-Number ofBedrooms 9 58 i Subdivision Name <br /> �v� �r- <br /> Block= CN'FA�.YWOoo - -mat A� o N <br /> DPublic/Commercial-Describe Usc <br /> ID City of <br /> DState Owned-Describe Use g <br /> CS Number ❑Village of <br /> t Town of MIDOLP?Q/J <br /> III.Type of Permit (Check only one box.on line A_ Complete line R if applicable) <br /> A SrNew System ILI Replacement System l QTreaament/flolding Tank Replacement Only I DOther Modification to Existing System(explain) <br /> 1 i 1 <br /> IB. D Permit Renewal D Permit Revision ID of Plumber DPermitTransfer to New Lim viOus Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV_Type of POWTS System/Component/Device: (Check all that apply) <br /> EINon-Pressurized In-Ground QPressurized In-Ground OM-Grade DMound a 24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> DHolding Tank DOther Dispersal Component(explain) DPretreatment Device(explain), <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(ggpdsf) Dispersal Area Requited(sf) Dispetsai (.5 Sy�em II4 ationq 3 <br /> (11 o _ `f 1.co 0 I l � �, l� 7 <br /> VI_Tank Info Capacity in Total ii of Manufacturer <br /> Gallons Gallons Units = o 1 12 <br /> Near Tanks 1 asinine Tanks ^ _ <br /> Doshm Chamber <br /> Tank i 2.22C42 I z I 45 6, r't' ki;0e I< I 1 1 • <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) i Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz _-----jam, 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 ( D�aatte Issued I I Issuing Is'‘IKAPproved ❑Disapproved S if ! 20 <br /> ❑O�Sner Given Reason for Denier c Xle-pAs <br /> IIL Conditions of Approval/Reasons for Disapproval <br /> I <br /> i <br /> I <br /> Attach to complete plans for the system and submit to the County only on paper not less than ti la x lI inches in sae <br /> SBD-6398(R 11/1 I) <br />