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.,s ' . RECEIVED W=11.11101' P.0_ County n7162 1° ' mby C, <br /> `,-- $P • '-. Matson.Wl 53707-7162 <br /> s ;�; 110V 10 (-3- 2I�t 5--0363 <br /> -k,-..."- <br /> ,..4. stye Ttaomctioa Number en it Application <br /> In accordance with SPS383..21(2),1 Adm.Code,submission ofthis forme)the appmptiate governmental unit <br /> is gybed pion to obtaining asanitaty permit No=Apollonian fat=for state-owned POD sow Project Address(if(Mama ma7Tmgaddress) <br /> the Ds3pc8me t of Safety and Professional Semis.Pin information you provide m7 r r.-e o n�6e l� t vF <br /> i in n State W <br /> I.Application Information-Please Pant AN Information past f <br /> Property Owna'sNtame <br /> vTE,�1� 44D COO nV PauS a d S- 3c,1- s 786-0 <br /> /tie Poway <br /> Property Owner's Man Adder }� <br /> 4)lQ 1....L - 8 t✓ DK-t vE Govt.Lot NI E. /�Section 3 0 Zip Code PbmeNnmber rj E v. <br /> c-m;��s��ppe ��r <br /> t\ PrO t�SciN 4�i I t 0 z T ~/ Ai; R 8 E <br /> IL Type of Building(check ail teat apply Lot4 <br /> I 8 Subdivision Name <br /> g1 or fa®lY>hm8-NOO� <br /> 131oet f _ <br /> QPubliiCo -De:mbeUse ❑CB of <br /> CSMNmmher 0r of OS7ateOwned-Desa7beUse &TOwaof NALQ/7t_ .TO"J. <br /> III.Type of Permit (Check only one box on line A.Complete line B if applicable) <br /> A. g]NewSystem El Repleeement Systan OTreamentllinkliog TankReplaeementOnly 00ther Morkficadm IDBmtiaSSysten(explain) <br /> �Ptambar I OkTmr mNtw List Previous PermkN®bcr and Date lsd <br /> >3_ 0PermitRmaral OPe�Revirim 0 otter <br /> Before Expiration <br /> IV.Type of POWTS (Check all thataPPlY) <br /> OiOn DI-Ground m in-Grote 13M-Grade ,Mosmd>24 in.ofmrtable soil 0Mound<24 in.of=bin soft <br /> n Holding Tank tDispelsal compaomt(amain) rot Device(explain) <br /> V-Dispersal/Treatment Area Information: <br /> Design Row(NA Design Soh Application Disposal Area Requbed(st) Dispeal AreaPmpased(sf) Symms Books <br /> (yob ■Co / /o 0 0 i, i /2 470 `Sef ,c7ee- <br /> Cap <br /> Gallons m Total 4 of M ine o <br /> VI.Tank Info °° o <br /> a <br /> Tads Gallons Units a s m m w is 0 it <br /> Hew Tanis Existing Septic or0&ingrant t�CJ(0 t..YJci e2 M e.44-oa 1� <br /> Dosing Chamber (.P S 0 t950 ) A. e-vocQ1� .,7/` <br /> VII.Responsibility Sintesneflt ent-I,the nodessigned,assume responsibility for of mePOWISshown Plum x m) ( grimess Phone Number <br /> AndreW W peinhotz (N. 220165 608-831-8103 <br /> 8103 <br /> Plumber's Adck ss(Sow,Cray,State,Eip ) <br /> 6813 County Highway K.Waunakee WI 53597 / <br /> e. At <br /> ViII.Co, a eadUse _� .41 6,� ,�/ <br /> ❑owns Given Rasan for Denial .- <br /> !0/ I- <br /> 1X.Conditions of Approval/Seasons for Disapproval <br /> Attach toamP4h plus far thesystem and sebmbto the Comte only an paper not than 876111 badmen me <br /> SBD-6398(R.11/11) <br />