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:. :,1.r:... 1 County ' � <br /> Safety and Buildings Division Dane Ct <br /> r-: 1)S 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> s ' S Madison,WI 53707-7162 <br /> '3 5-GD24 <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 353 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 be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. L A UtZ�L. ��-I. ApplicationInformation-Please Print All Information es G7 A'j <br /> Property Owner's Name Parcel# <br /> A LTECKA D ES 162 N NU■ (F-s LL( 01O&- 2 03- 00r7 q - 0 <br /> Property Owner's Mailing Address Property Location <br /> 29'72 Couari t-tLbvL-LVJA4 MM Govt.Lot <br /> City,Stale Zip Code Phone Number 20 <br /> F(TG��2G, �( p r?l I 14 '�� �� '4, Section <br /> II.Type of Building(check all that apply) Lot# <br /> T 11 N: R 3 E <br /> aI or 2 Family Dwelling-Number of Bedrooms 19 Subdivision Name . I <br /> Block# S pa,ac,E L'OI N <br /> OPublic/Commercial-Describe Use <br /> ❑City of <br /> -'-•--/ CSM Number O Village of <br /> OState Owned-Describe Use 1 <br /> DA Town of 14 ioo., wiJ <br /> III.Type of Permit: (Check only one box on line A. Complete ine B if applicable) <br /> A. fNew System ❑Replacement System ❑Treatment/#Iolding Tank Replacement Only []Other Modification to Existing System(explain) <br /> B. O Permit Renewal O Permit Revision O Change of lumber 1 DPermit Transfer to New List Previous PermitNumber and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all th t apply) <br /> SiNon-Pressurized In-Ground []Pressurized In-Ground ❑At-Gr e ❑Mound>24 in.of suitable soil ❑Mound<24 in-of suitable soil <br /> 0 Holding Tank Other Dispersal Component(explain) OPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation r e / <br /> (,¢do . `I /564) /L 77Z y-7,6/ %.ri96.; 9.cT <br /> VI.Tank Info Capacity in Total #of Manufacturer 2 c <br /> Gallons Gallons Units , o y ° <br /> .rs 9 :J » <br /> New Tanks Exist ine Tanks L o - 2 .c .1 3 <br /> —O iit TA rn —O c.. <br /> Septic or Holding Tank (a2)to I 8(„ -2- M g,t <br /> 1E x <br /> Dosing Chamber ,5c) G50 i MEAD <br /> E )‹. <br /> VII.Responsibility Statement-I,the undersigned,assume responsility 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 /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agen e <br /> / ❑Owner Given Reason for Denial • 45 t e ‘V $ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 1-- ( l tti t .�('�/f -C v o-( S/ I; 1 iIUL cr L7eV-e--A- trt� C B tee- e <br /> 1 •/ • <br /> Attach to complete plans for the syvstem and subrit to the County only on paper not less than 8 in x 11 inches in size <br /> SBD-6398(R. 11/11) <br />