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't. aR-ti.?%)- County <br /> • = Safety and Buildings Division Dane `j1:1 <br /> i D 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> \SPS 1-i Madison,WI 53707-7162 '3--2o��J �� <br /> ' �- <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 POW TS 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(lxm),Stats. f�ts n Q�� <br /> it Application Information-Please Print All Information v <br /> Pro _ (c/o .I�: 'iAt,J,�( C E,R LE 1 Pamd# <br /> Do,nku, I(ER,I.TE aacelz 13L4tLoeFgs ttgc ! 0911- 303- 12.�to - t3 <br /> Owner's Mailing Address ' Property Location <br /> v 5-r E N AI Nt <br /> _i__ ~r Su Lr£ I04 Govt Lot <br /> iC,i y,,State �� 1-' / Zip Code Phone Number 1 2 O <br /> W.4 FtWr V l iE ,4J l N W /<, S W /s,Section 7 <br /> 5359'7 T 9 N; R II E <br /> IL Type of Building(check all that apply) Lot# <br /> X31 or 2 Family Dwelling-Number of Bedrooms 5 v (Q Subdivision Name <br /> Block# BRISTOL. C-)Al oegs <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ®Town of $12,1 S' OLD <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `t IRINew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B.!/❑Permit Renewal ❑Permit Revision ❑Change of Plumber ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWYS System/Component/Device: (Check all that apply) <br /> IgNon-Pr ssurvcd tI-n--lGround Urnssurized In-Ground DAt-Grade DMound>24 in.of suitable soil ❑Moumd<24 in.of suitable soil <br /> ❑Holding Tank t r ther Dispersal Component(explain) DPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System <br /> Elevation <br /> 15o i/ -/ /97.S , l & 9y.Y,43.,9 <br /> 2.g 92�9. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units , d o d o <br /> New Tanks Existing Tanks `a' o ,.. w 3 <br /> , " a, <br /> a,U 'm m �C7 -. <br /> Septic or Holding Tank '650 I�Q 2. Mr A o <br /> X <br /> Dosing Chamber Soo boa l M ECroE Jc <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbers Signature 1 MP/MPRS Number 1 Business Phone Number <br /> Andrew W Meinholz . ,(.-'-. 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> i <br /> N.V111.County/Department Use Only _ _. <br /> proved ❑Disapproved Prnnit Fee Date Issued Is' _Agent 's:.... ' �'ACI <br /> ❑Owner Given Reason for Denial 1. /0/11- _ <br /> IX.Conditions of Approval/Reasons for Disapproval r''' <br /> Attach to complete plans for the system and submit to the Comity only on paper not less than 812 a 11 inches in nor <br /> SBD-6398(R.11/11) <br />