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County <br /> Safety and Buildings Division Dane <br /> z : I _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S p 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 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 he used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. C i*M i1 o Ns f1 u, J <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> N VA-I-A-v..(., A .A r-E K EA-NA 0508— 314- O l?`7- O <br /> Property Owner's Mailing Address Property Location <br /> 00?) S`T g.lrl:G1 1.-I-T LA tiE Govt.Lot <br /> City,State Zip Code Phone Number NE, V/a 5E, t/4 Section I <br /> . <br /> Cc1TTA-E i C-1011`. kAi I 5352.'7 T aj N; R 5 E <br /> II.Type of Building(check all that apply) Lot# <br /> kil or 2 Family Dwelling—Number of Bedrooms 5 -5 b Subdivision Name <br /> Block# 5 le,I DLE RID( E <br /> ❑Public/Commercial—Describe Use ['City of <br /> CSM Number ❑Village of <br /> ['State Owned—Describe Usc C p g(�,&)cl t✓ LD <br /> Town of J <br /> HI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' El New System ❑Replacement System ['Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ['Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> dNon-Pressurized In-Ground ❑Pressurized In-Ground QAt-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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sO System Elevation <br /> q 50 , `7/ /8-7S- /S90 9a S f 39 5) .4?r <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> a v <br /> Gallons Gallons Units 3 0 v _ h •9 <br /> New Tanks Existing Tanks � o = " <br /> a.r) in ti cr _U G <br /> Septic or Holding Tank I l S 5 U I t,, I tu c A 0 <br /> ,_- <br /> Dosing Chamber <br /> WI.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 Meinholz 4)• 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 Date Issued Issuing Ag ignature <br /> jg Approved 111 Disapproved S .4 ✓'✓ 7—Z ` —/J (p �a�/�., <br /> ❑Owner Given Reason for Denial <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 in x 11 inches in size <br /> SBD-6398(R. 11/11) <br />