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County <br /> Safety and Buildings Division Dane PA i',- <br /> . 41 .1, <br /> x - 0 201 W.Washington Ave.,P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) . <br /> ; S ' '7 <br /> , P Madison,WI 53707-7162 <br /> •-• ' S : 1 -.),...----.2,----__I, —1---i '-i-\ if <br /> ._i .--z-'--..)11(:. <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(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(l)(m),Stats. e.'_5,it;_ .... -re_A-I L. <br /> I. Application Information—Please Print All Informatio <br /> Property Owner's Name Lc '-IC) AlLtotAi\bc-e- ) <br /> Parcel# <br /> PA LtL(. 0 i..1 DEVCLOp M E 1.4-r oci II - 1 2---1 <br /> - <br /> (--1--0AAE-.. 1 NA C, <br /> Property Owner's Mailing Address Property Location <br /> 5E3& (3ik,t.ip I z -, <br /> Ac <br /> Govt.Lot <br /> City,State Zip Code Phone Number N,E. %, 1.1 6 vi, Section IZ. <br /> IkA Ai4S14-kl-a— \ILI 1 -.5c._-_;5"9 <br /> T 9 N: R I t E <br /> 11.Type of Building(check all that apply) Lot# <br /> gi or 2 Family Dwelling—Number of Bedrooms 14 53 Subdivision Name <br /> Block il r.. <br /> DittAmi-wu L-re...ta.- e..._ <br /> OPublic/Commercial—Describe Use <br /> 0 City of <br /> CSM Number 0 Village of <br /> ['State Owned—Describe Use <br /> NI Town of ,-;T--i,i_. <br /> HI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. [5.1d New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only []Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision [jj]Change of Plumber [I'Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 1zNon-Pressurized In-Ground ['Pressurized In-Ground 0At-Grade 0Mound>24 in.of suitable soil []Mound<24 in.of suitable soil <br /> 0 Holding Tank DOther 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 /> (1.0 0 , ei 4.1 /5 0 e.) Vair ri tiq az i I, 91,o', )4,5' <br /> VI.Tank Info Capacity in Total /1 of Manufacturer <br /> 0 <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks .= 0 1.. tol •••= <br /> E:o iii ri, to ir. F.3 :— <br /> Septic ortteldies Tank I A569 -._ 11V0 at lkiff A o 6 ?< <br /> Dosing Chamber _ Li :.)-c) .-- 6,50 A MEivor <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Number's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz ,.4— k.) . ---N- --- 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K.Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued lssui • t S' atu <br /> gsproved 0 Disapproved <br /> S ..-4/2. ..., , <br /> G-1 7--2-01 6 C 24e#/ "---- <br /> 0 Owner Given Reason for Denial ---- i,...) t. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 1-* Fcervfe Itioeno fiffro.-, R,6-7 -it-ffitc..r 7 f t T(' /14(Tr <br /> (Ac /lex Af,tifeAc cww( -7(e;"(, to/eor(--4,--r Fv42.1-1 .ro/e- cwkkeoic._- __9A- <br /> / <br /> (OIL )(olverfoy, A-rto Vey?ati.,44 "rgAric <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R. I I/1 I) <br />