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<br /> - County /
<br /> Safety and Buildings Division Dane
<br /> B S 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be tilled in by Co.)
<br /> P S Madison,WI 53707-7162 3 }//rr
<br /> C
<br /> Sanitary Permit Application State Transaction Number
<br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this f..••• t a ro Hate governmental unit
<br /> is required prior to obtaining a sanitary permit. Note:Application forms .0 t j e ) a .. •to Project Address(if different than mailing address)Ait,the Department of Safety and Professional Servies. Personal informatio 'y•. d u r s: . Ty
<br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. t
<br /> L Application Information-Please Print All Information FEL1-4-21p6
<br /> Property Owner's Name Parcel#
<br /> K 0\.)C V',?-I'', :1 _ .: ' is Health MDC ii \ - 1\.‹;a, 6' C'� ...
<br /> Property Owner's MailingAddresil M1ETIf'a ea th Property Location
<br /> }, ` '
<br /> c-i--I t i�` v i",,,t", L...11 Govt.Lot ____
<br /> City,State - _l ' Zip Code Phone Number 1 , ' ' �`
<br /> C, :/V t(...- /, ��i� /Q, Section t ✓
<br /> J i 3\'� C),- r�t Y'\ Z fit` 1 5 ? � (/‘ (-' 1 t E
<br /> 11.Type of Building(check all that apply) Lot# T N; R
<br /> g!or2 Family Dwelling-Number of Bedrooms LL)
<br /> k Subdivision Name
<br /> Block#
<br /> ❑PublicJCommercial-Describe Use
<br /> 0 City of
<br /> ❑State Owned-Describe Use CSM Number ❑Village of
<br /> l> c,l- Town of 'Sc s• 1`';'..-`1'. .,;'-
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. J New System El Replacement System Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain)
<br /> t - ,( ... AppEND /JJ .1,e..:•-, C.)t..A:i,0 7, :.,.i iDL \
<br /> R. ❑Permit Renewal CI Permit Revision ❑Change of Plumber ❑ List Previous Permit Number and Date Issued
<br /> Permit Transfer to New
<br /> Before Expiration Owner 1 -i' 4-- Gs ,
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply) Dil•r(( eret.. y
<br /> DNon-Pressurized In-Ground Pressurized In-Ground Pt-Grade 0Mound>24 in.of suitable soil 0Mound<24 in.of suitable soil
<br /> 0 Holding Tank ❑Other Dispersal Component(explain) Pretreatment Device(explain)
<br /> V.Dispersal/Treatment Area Information: fr,r G. ,f?,yt— 1
<br /> Design 1Fllow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st)�1/`/System Elevation
<br /> ' J 2,0S. /
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units x, 3', c 1, i..)
<br /> New Tanks Existing Tanks 4 ;' 2 '• e, N h
<br /> 0 s a r
<br /> a U in v, r U
<br /> Septic o:J�tl+og Tank l� J j --- � � ;� f ?� /J 3 M L:',A
<br /> { ./
<br /> Dosing Chamber
<br /> VII.Responsibility Statement-t,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) 11 mber's Signature MP/MPRS Number Business Phone Number
<br /> Gary A Meinholz ) ,. -A• yf'1 1rir -\ 222318 608-831-8103
<br /> Plumber's Address(Street,City,State,Zip Code) 1
<br /> i.
<br /> 6813 County Highway K,Waunakee WI 53597
<br /> VIII.County/Department Use Only
<br /> proved Disapproved Permit Fee Date Issued ,,// Issuing/AA t Si�.attire
<br /> ❑Owner Given Reason for Denial $ r -7 212.yl 6 / / /•
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> �rL'1J �fL�
<br /> --TIN/0 D Ieififteper to r fir. 7: 4-- (74- (oS(- ( S-
<br /> r CO 241 A 68.7x - (67. 6
<br /> " .s it. __
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 r2 x II inches in sire
<br /> SBD-6398(R. 11/11)
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