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_ County <br /> Safety and Buildings Division Dane fri <br /> `\D s 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ti ,P ` Madison,WI 53707-7162 <br /> I _S 1 3"201`-3 OC)2..G 9 <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 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. 0 5 LO .o&o <br /> _I. Application Information—Please Print All Information 05 t1 <br /> Property Owner's Name Parcel# <br /> Piut,Sc J DEL) L.opm,Ery LLC (c/0 Aki131A-kk r 1-66 0911- 194- 45ia --a <br /> Property Owner's Mailing Address —�- Property Location <br /> ✓r�.5.a lr`11�'f S5L,A N.D 1 2.(t'.t2,A C Govt.Lot <br /> City,State Zip Code Phone Number Q <br /> . SW /, S E /, Section i9 <br /> Mil.251-t`A L-L. V-41 53559 — T 9 N; R I t E <br /> H.Type of Building(check all that apply) Lot# <br /> kit or 2 Family Dwelling—Number of Bedrooms 2 Subdivision Name <br /> Block# LEUMA JIS / ()P LTIONJ <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> OState Owned—Describe Use CSM Number ❑Village of <br /> Town of 1E) O L <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 'New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. [11 Permit Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.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 0 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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> CO U O ,. 4. V i c,G o V / 4/%6 ,/'' V,'V,' et 4, SI, Pr.., <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 0 o v o <br /> New Tanks Existing Tanks t o y , m 2 <br /> a U rn w 0 O. <br /> Septic or Holding Tank q i h 4,/UJ_ <br /> on KJ(-17 ld-iJ WI,.�PrD� <br /> Dosing Chamber (2l5 o , OA. <br /> I <br /> ' . E x.... <br /> VII.Responsibility Statement-I,the u • signed,assume responsibility for installation of the POWTS'■own on the attached plans. <br /> Plumber's Name(Print) Plum is Signature MP 'RS Number Business Phone Number <br /> Andrew W Meinholz 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip ode) ___, <br /> 6813 County Highway K,Waunakee ■ : • 2 <br /> VIII.Conn /De artment Use Onl j 4 <br /> Permit Fee Date Issued 9 g A igna <br /> pproved iii Disapproved $ - =4 <br /> ❑Owner Given Reason for Denial ■N e I 15 i!,,�� � --, <br /> IX.Conditions of Approval/Reasons for Disapproval _ <br /> ts-li -, M, 1'7--(_ 'e2TZ.— 'C7-`1:Fez,- --5-ji.) 0-CW'Ziz4 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 a 11 inches in size <br /> • <br /> SBD-6398(R. 11/11) <br />