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' County <br /> - Safety and Buildings Division Dane <br /> z : 11 g - 201 W.Washing 7 <br /> s ~ ° Madison - Iii Sanitary Permit Number(to be filled in by Co.) <br /> s _ , <br /> 4.."..- <br /> AUG Y 3 2015 <br /> 3 -201c-- 6625'1 <br /> Sanitary Permit Application S ate Transaction Number <br /> In accordance with SPS 383.21(2), t' pub11C Health MDC I,� <br /> (2),4yis.Adm.Code,submission of this form to t�l9ggd�K �:titk'��F�f Ott <br /> is required prior to obtaining a sanitary permit. Note:Application tbrms for state-ownc Nj i � o 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. PA P-44 E� ?Ass <br /> I. A A.•lication Information-Please Print All Information F <br /> ry Owner's Name Parcel II <br /> C gtl 193- Oct,c-p <br /> Property Owner's Mailing Address Property Location <br /> PO BOX 404 Govt.Lot <br /> City,State Zip Code Phone Number r q <br /> 3unr PRA-142i L-' 141 15 3 59 0 `''� 1/4, SW +, Section / <br /> II.Type of Building(check all that apply) Lot it T N; R E <br /> g( PP Y) t <br /> ®I or 2 Family Dwelling-Number of Bedrooms !1 tr." 1 Subdivision Name <br /> Block n PA R.14 egg$ PLasC,t~ <br /> DPublic/Commercial-Describe Use <br /> D City of <br /> OState Owned-Describe Use CSM Number ❑Village of <br /> JTownof 13 12L3TD1.... <br /> III.Type of Permit: (Check only one box on line A. Complete line B if npplicable) <br /> A. �New System ys Q Replacement System OTreatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal D Permit Revision D Change of Plumber nPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T 'e of POWTS S stem/Com•onent/Device: (Check all that a• •I <br /> ®Non-Pressurized In-Ground DPressurized In-Ground DAt-Grade OMound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank DOthcr Dispersal Component(explain) DPretreatment Device(explain) <br /> V.Dis•ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispe df Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> L000 - (° 1. /dod I J// 3S v (/09..9 / rog.g, /6s.(5-� <br /> VI.Tank Info Capacity in Total of Manufacturer <br /> Gallons Gallons Units L o` o <br /> New Tanks Existing Tanks <br /> ) s J u <br /> i J - l <br /> n_n U mom, a. 0 E. <br /> lirialiaill Dosing Clratnber `_5 o to 50 ' NASA1) J(28 lallIP2MIAP IIIIIIIIIIISMIII MI <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 -- 1-i-.)- -y I 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.Court /De•artment Use Oat / <br /> ,r pproved ❑Disapproved Permit Fee Date ued lssuin /g • I ,�V��/� <br /> ❑Owner Given Reason for Denial r3/ ✓ 1 /77/S 6 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> /J13"- .: 717 C 4 CSk Wt- --t-t - *-T----'' ) Ie i t ' ` <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 til s 11 inches in size <br /> SBD-6398(R. 11/11) <br />