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V'ersnrsirtT County <br /> 4/`a � \ Safety and Buildings Division Dane t`'� <br /> i /` \ 201 W.Washington Ave.,P.O.Box 7182 Sanitary Permit Number(to be filled in by Co.) <br /> �\t\Sp Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required pror.o obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Deparbneit of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stats. BA/ ' ^U ICEL, + h_ ,L <br /> I. Applicat of Information-Please Print All Information 4 i-/-r �/'nv <br /> Property Owner's Name Parcel# <br /> MRE.0 11(4 MADlso NI LI-C or/O15 -- 203- , 18&-O <br /> Property Owner'.Mailing Address Property Location <br /> 1pbe1 Sour 14 �_OvJty E D(2lve Govt.Lot <br /> City,State t,� d+ Zip Code Phone Number , <br /> M�(�l 50+� 1 1 3 `� S c. 'Vs,_SW Vs, Section 10 <br /> T `7 N; R 8 E <br /> II.Type of Su ding(check all that apply) Lot# <br /> K1 or 2 Family Dwelling-Number of Bedrooms 5 'd V Subdivision Name i <br /> FICA LO'`' , <br /> Block# S PKAAC,.E FICA L4 vV <br /> ❑Public/Con menial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> I l T o w n of tat I)viz T'o ) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. isiN.system y ❑Replacement System ❑TreatmendHolding Tank Replacement Only ❑Other Modification to Existin g System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑p List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ['Permit Transfer to New <br /> Before_Irpiration Owner <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Task l (Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dlspersal/Treatment Area Information: <br /> Design Flow(gpd Design Soil Application Rate(gpdsf) Dispersal Area Required(si) Dispersal Area Proposed(st) System Elevation / i <br /> 30 /f7,-S". /g O <br /> 9'67 goZO' 61.. 50.5- <br /> VI.Tank Infii Capacity in Total #of Manufacturer a <br /> Gallons Gallons Units .ggg <br /> New Tanks Existing Tanks i; .. <br /> Septic or Holding Tank '(.50 1 .2 I AoE \, <br /> Dosing Chamber (11000 800 I KA5ProE X. <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Melnholz r-4.44— t --1-----t7, 220165 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 /> pproved ❑Disapproved Pe 1t Fee Date Issued Issuing AI. n <br /> ❑Owner Given Reason for Denial <br /> S Jt- ' 4''1'45 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RECEIVED <br /> APR 0 8 2015 <br /> Attach to complete plans for the system and submit to the County only on paper not leas than 81/3 x it inches in size <br /> public Health MG( <br /> Environmental Health <br /> SBD-6398(R. 11/11) <br />