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_........... <br /> ,:,; :.::7t,i,s ' County <br /> Safety and Buildings Division Dane <br /> D _ 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S 13 Madison,WI 53707-7162 db9 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 33321(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 fcond <br /> purposes in accordance with the Privacy Law,s.15_04(1)(m),Stats. �T �U,C �� �(L <br /> I. Application Information—Please PrintAil Information RECEIVE Spit.' <br /> Property Owner's Name , ' j rcel# <br /> So I.'1`t.( A-►.L r7 S (r-1 e L L`/ W A Lt.,A C E FEB Fib U 0 6 2016 . 0608- 3 dL- 21 S Lo-- Q <br /> Property Owner's Mailing Address Property Location <br /> Pulilie I1 @altil MDC <br /> 17 4 (3 2 CLA■/j WA•4 th iIofiffl ental Health Govt.Lot <br /> City,State Zip Codc Phone Number fq C r fa 1\41,4 V4 Section 3 I <br /> ki',A 1)I Ste. 41J I S T 0 N: R 3 E <br /> 11.Type of Building(check all that apply) Lot y <br /> Mi or 2 Family Dwelling—Number of Bedrooms i (p 21, Subdivision Name ,{ <br /> Block# NuMt Po b <br /> ❑Public/Commercial—Descnbe Use <br /> ['City of <br /> _) <br /> CSM Number ❑Village of <br /> ❑State Owned—Describe Use r� <br /> I'Town of <'h I�..L is G1 F 1 E---L1) <br /> HI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 'New System ❑Replacement System 0 Treatment/1-Iolding Tank Replacement Only Daher Modification to Existing System(explain) <br /> B. List Previous Permit Number and Date Issued <br /> ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ,Norm-Pressurized In-Ground ['Pressurized In-Ground at-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> p Holding Tank DOther Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) y Dispersal Area Proposed(sf) System Elevation , <br /> 9co ,/ . (i f . -S, 2.s: 's.5-_y, o 6/s �3 G,/ <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units al ° <br /> New Tanks Existing Tanks . o v <br /> .-U cn 1-4 r, ^. O <br /> Septic or UoldiarT�rli' jc ...� J � co 0 ,�. ,�l e c.-.AC ><' <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz „,,,.4--..--.P.----- <br /> „,.4--..-_.e___ 4-k.) 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 /> ❑Approved 0 Disapproved Permit Fee Date Issued Issuing A” 'iv- ' , ature <br /> ❑ Owner Given Reason for Denial S /(v Z/c57/6 2r.. !/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in size <br /> SBD-6398(R. 11/11) <br />