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- _ I County I <br /> a - Safe and Buildings Division Dane <br /> z VG <br /> .: B s _ 201 W.W hington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by <br /> P S Ma ison,WI 53707-7162 <br /> (3 2 0(5- Co2C--6 <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 prior to obtaining a sanitary permit. Note:Application forms fDr state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal infomiation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law;s.15.04(1)(m),Stats. I TIdt M(3LePG1m.1\1 Ti2.A t t__ <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel <br /> DMZ- S LAU 12.Ar 4- -UMP I42E y Or?O - 293— 1034-Q <br /> Property Owner''ss Mailing Address Property Location <br /> to Z2 (..it A`t x Tj2A.t L Govt.Lot <br /> City,State Zip Code Phone Number INIlL V. S kki V4. Section Z 9 <br /> fkUI50tJ UV , �Z1 ''7 T r7 N: R 8 E <br /> II.Type of Building(check all that apply) ^ Lot <br /> �! or2 Family Dwelling—Number of Bedrooms_ " 1 4 Subdivision Name <br /> B,ockr li ,MBLEDGti1N Map.tLs <br /> ❑Public/Commercial-Describe Usc ID City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use M I DQL,E-�nt� <br /> Town of <br /> TII.Type of Permit (Check only one box on line A. Complete line 13 if applicable) <br /> A. ®New System ❑Replacement System ❑Treaitnent/I-lolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision C1 Change of Plumber 0Permit Transfer to New <br /> Before Expiration Owner ` <br /> IV.Type of POWTS System/Component/Device: (Check all the 'pl ) <br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground OAr-Grad & ,lound>24 in of suitable soil 0 Mound<24 in of suitable soil <br /> 0 Holding Tank Either Dispersal Component(explain) Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) I Dispersal Area Required(s0 Dispersal Area Proposed(sf) System Elevation S l iE <br /> (,000 ✓= L/( 1 ,% /Sbv / Soa Ste' <br /> VI.Tank Info / Capacity in Total II of Manufacturer <br /> Gallons Units ° u <br /> Gallons p. ci , <br /> . 3 - -,- . <br /> New Tanks Esinine Tanis - <br /> _ U ii: A' n - v <br /> Septic or Holding Tank .2 569 OVA$'�A -2-. I A E v E >< 1 <br /> I <br /> Dosing Chamber 0 5 Q I use I 1 1.4 E_A-D E._ -KI I <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 I Business Phone Number <br /> Andrew AN Meinholz t, !.-1. 220165 608-831-8103 <br /> Plumber's Address(Street City,State,Zip Code) i <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Permit Fee v Date Issued Issuing Agent Signature <br /> XApproved ❑Disapproved S j (f fs 0 <br /> ❑Owner Given Reason for Denial ` (" 7-3(- <br /> _ 3( I S <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 rr2 x 11 inches in size <br /> SBD-6343(R. 11/11) <br />