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r •rlrno;�.T, County <br /> ',` Safety and Buildings Division Dane <br /> • ; D SP,,' \,-.� 201 W.Washington Ave., P.O. Box 7162 <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> 1"j �' Madison,WI 53707-7162 <br /> `' 1 '3-2 ()r5 OD3v <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 be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. L rU (v,E <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name ly r.tht OVJI�i C1 44 E P4 \ Parcel# <br /> ME 4001/41.1 R>f�ri) �L-C CC/0 <ItEtM 0c6 E(CA'JA/76itik 0'7o5-- 524 - .1 65(Q - 0 <br /> Property Owner's Mai ling Address Property Location <br /> CQ er ` ( )Lt T/ 17 I,. V\ 4 i (C <br /> Govt.Lot <br /> City,State t /r + Zip Code Phone Number S I/t/ 1/4, 5F... '/4, Section 5j G, <br /> \,i♦N tV I�1�-F_'E 1/ 1 1 535.i 7 ((tab)0-5 i '-0(05 T '7 N; R B E <br /> II.Type of Building(check all that apply) Lot# <br /> RIl or 2 Family Dwelling—Number of Bedrooms 4 ce Subdivision Name <br /> Block# ME A ocu./ 12,OA i) E5 7A S <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of ,A 1 <br /> I Town of ,�v((o U c E TU 1V <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System El Treatment/Holding Tank Replacement Onl y ❑Other Modification to Existin g System(explain) <br /> B. El Permit Renewal El Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration 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 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(sf) System Elevation <br /> O lA . Lf /-cc: Q /t/ °7 c /01/.0 ' /d ;,c) <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units N o 0 0 <br /> Now Tanks Existing Tanks w ' ~o8 a 2 co <br /> a.u v5 1„ VD w 0 a. <br /> Septic or Holding Tank t y, �y ` `�,0/ • EA-Op <br /> Dosing Chamber 1 o&5 0�p 1 o�r-i5.0 s•�) M E A l)1-._ 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 Meinholz (u , 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VDT.County/Department Use Only <br /> ffi Approved ❑Disapproved Permit Fee Date Issued Issuing Age _ - .• e <br /> ❑Owner Given Reason for Denial <br /> $ 3E r 7-2 I-15 <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 1/2 x 11 inches in size <br /> SBD-6398(R. 11/11) <br />