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County <br /> = Safety and Buildings Division ID/AA/E. I <br /> El: _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) I <br /> Madison.WI 53707-7162 � <br /> ( 3- ats-od274( <br /> lication ( State Transaction Number I <br /> Sanitary Permit Atryc� I` <br /> In accordance with SPS 3S321(2),Wis.Adm.Code.submission of this form to the appropriate governmental unit I <br /> is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS arc submitted to Project Address(if different than mailing.address) <br /> the Department of Safety and Professional Servies. Personal information you provide max be used for secondary I <br /> purposes in accordance with the Privacy Law,s.Ii.W(I)(m).Stars: RECEIVED ROC.V,Y t� RC Al> ` <br /> I. Application Information-Prose Print All informed+ RECEIVED 1 N <br /> Property Ot:ner's Name AUG 2 6 2015 Pa 050 _ 104_ 9001- 0 <br /> Tom. p,w KA-rt-fy 14e-Lk/V--W,3�A�d p <br /> Property Owners Mailing Address Property Location i <br /> I I Public Health MDC <br /> 53(04 RUGK�( W-ILk- ROAD Environmental Health Got2Lot <br /> CCity,State (Zip Code m(Phone� nbv <br /> Ste yy I <br /> S E ;_Section 70 <br /> 1�IlDdIFTON 1111 j 535''(eZ j T I.• R c. r <br /> 'IL Type of Building(check all that apply) Lot 4 I <br /> Ior2 Family Dwelling-Number of Bedrooms 3 I Subdivision Name ,. <br /> Block= 135.214 14te M s! <br /> ❑PubliclCoumtercial-Describe Usc <br /> I City of <br /> CSM Number I❑Village of I <br /> I❑State Owned-Descnbe Use I <br /> I2 Town or SeleI lJ(wc t l.La <br /> ` ITT_Type of Permit- (Check only one boa on line A- Corrtplete line R if applicable) <br /> A. ❑New System Replacement System I❑Tte4lnent/Ilolding Tank Replacement Only I❑Other Modification m Existing System(explain) I <br /> / I <br /> I( i i j <br /> B. ❑Permit Renewal ❑Permit Revision I❑Change of Plumber I❑Permit Transfer to Nay Led Previous Permit Number and Date lssued <br /> Before Expiration I I Owner <br /> I IV.Type of POWTS System/Component/Device: (Cheek all that apply) I <br /> Ila Non-Pressurized In-Ground ❑Pressurized ln-Ground []At-Grade ❑Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑Holding Tank 1]Otha Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> i <br /> IV.Dispersal/Treatment Area Information: ...I. <br /> Design Flow(gpd) Design Soil Application Rate(gpdsi) ' dispersal Area Required(sf) Dispersal Area Proposed(sr) ' System Elevation , <br /> 450 i , V i/aC // -e.• 5'3.9"y3_s 91i 92. <br /> Vi.Tank info Capacity in Total of Manufacturer = I <br /> Gallons Gallons I Units S n ( j - - <br /> Nes.Tanis I Exatina Tanks I I ' = I ,f ° _ <br /> =V s <br /> 1 XI vI I rl <br /> I Septic or Holdios Tani: I 1 <br /> 1 1 IXI I 1 <br /> Dosing Chamber I 1 ooU i I Ip i 2 1 M�.r-+oE <br /> VTT.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(Print) Plumber's Si_,{ature vIP/MPRS Number Business Phone Number <br /> Andrew W ivleinholz I _,'•✓ . L/ , 220165 608-831-8103 <br /> Plumber's Address(Street.City,State,Zip Code) (�f <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> I Permit#tie rry Date Issued I Issuing t Sigttature <br /> PProved ❑Disapproved ' 5 j i O Of T/ 8-27-/J`"1 �1.`-047/}/iCJ�"'v <br /> ❑Oaircr oivcn Reason for Omani 1 1 V r <br /> iIX.Conditions of Approval/Reasons for Disapproval ' -Q e n _ // I <br /> .fG CLoLC _ I 1 <br /> 1 <br /> Attach to complete plans for the scstern sad submit to the County only on paper not less than S in 1 II inches in size <br /> 580-6393(R.11/11) <br />