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County -- <br /> Safety azIgEoCeVE Dane <br /> u s _ 201 W.Wash' DSaoitary Permit Number(to be filled in by Co <br /> Madison, <br /> S <br /> JAN 062016 p3 -20/6-00006 <br /> ■ <br /> Sanitary Permit Application <br /> Public Health MDC State Transaction Number <br /> In accordance with SPS 38121(2),W¢Adm.Code,submission of this form to thenj.1 rl�r�.i r nk t• <br /> is requited prior to obtaining a sanitary permit Note Application forms for state-owned POW S are submitted to Project Address(if different than=Wing 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(IXm),Stars <br /> LApplicationInformation—PleasePrintABInformation LACK C(F iZIZ`f' Gilt2� <br /> Property Owner's Name Parcel <br /> ifli3rKK CO04tc' TQlaniA Rwc (C/0 Tfw'? PutLpERS(L O(COe-353-W-t0-- 0 <br /> Property Owner's Mailing Address Property Location <br /> Z50I VIESr BEL.TL1tJE I60N4,./Ay Govt Lot <br /> City,State 'EV Phone Number 33 5 <br /> �� •7 r 3 � N4>/ '�. S Id '/S Section <br /> IUD I SG..i T 1p N: R 8 E <br /> IL Type of Building(check all that a y) Lot <br /> r1or2 Family Dwelling—Number ofB Dins 5 Y 14 Subdivision Name <br /> BI g <br /> ❑PublidCommercial—Describe Use <br /> ID 0-11Y aF <br /> ❑State Owned—Describe Use CSM Number ❑Village of a <br /> 11-1.0.3t y I_ ®Town of l NI A <br /> ILL Type of Permit (Check only one box on line A. Complete line E if applicable) <br /> A ®,New System ❑Replacement System Tn�mtent/flold' Tank Replacement Only Existing System(explain <br /> ❑ mg ep y ❑Other modification to ) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ['Permit Transfer to New Last 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 ❑Mormd>24 in.of suitable soil Mound<24 in.of suitable soil <br /> ❑Holding Tank lather Dispersal Component(explain) DPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) D Area Proposed(sf) System Elevation <br /> x15 a ✓ , ••----i A 5o �//.SS C S rte-AI--S t-r� <br /> VI.Tank Info Capacity in Total P of I Manufacturer , <br /> Gallons Gallons Units r 3 ^' .. e <br /> ? Taft Ec'snio;:Tames 2 5 u — a .e_e _ <br /> =0 rnH se _G <br /> Septic-cc Holding Tm* U.050 ItS 0 3 r teA-o- <br /> ,bring clamber 800 i?J©O I i✓1 E A of_. f <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Marne(Print) Plumbers Sinnamrc I MPJMPRS Number 1 Business Phone Number <br /> Andrew W Meinholz L. 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zap Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Departtnent Use Only <br /> Q Approved Q Disapproved Permit Fee <br /> U Owner Given Reason for Denial 5 "2'1 - `fit .7 trio %, �- <br /> IX.Conditions of Approval/Reasons for Disapproval - <br /> ' <br /> S , <br /> Attach to complete plans for the system and submit to ' .•.........• . . <br /> _ . .. . •,-.,_ sum <br /> SBD-6398(R_II/11) <br />