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---- , County <br /> t ��y� Safety and Buildings Division Dane <br /> ( � s 2 01 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> f1` <br /> Madison,WI 53707 7182 <br /> 4414■ <br /> "y7n1N.� !� <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 POWYS 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(1Xm),Seats. (• L S I-1 D AI S�( e G�11T <br /> I. Application Information—Please Print Ali Information RECEIVED -r <br /> Prgpdrty.Owners Name am51717-- -- <br /> L NI,R. C 11 H MIA D 1 k) LLC FEB 2 9 2016 o rz S a03 05 0 <br /> Property Owner's Mailing Address Property Location --' ' ---...4- <br /> ' <br /> to t G( C,.J n -Tow U [ �,V Public Health MDC Govt.Lot 1- ' (..$ <br /> � Environmental Health <br /> City,State Zip Code Phone Number Siff►/, <br /> S Vt( / <br /> , Section Z U <br /> �n 1�t 5C/0 WI 53 '7 -6 T , I/ <br /> N; R 6 E <br /> U.Type of Building(check all that apply) i'C " \ Lot 4 <br /> [ 1 or2 Family Dwelling-Number ofBedrooms ( ... <br /> �/ 1 1 Subdivision Name <br /> „___-".,. Block# SP RUL♦s- 4404.'014) <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ['State Owned-Describe Use CSM Number ❑Village of <br /> [CI Town of (VA I I),)4,- -77:)t0 <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 11 INew System ❑,Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber OPennit 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 /> ❑Non-Pressurized In.t3round ['Pressurized In-Ground ❑At-Grade ErMotutd>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> :kidding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Designilow(gpd) Design Soil A.. lication Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed Of) System Elevation <br /> V1 p v , 4,12 5 /:2S o 5. r AT S i <br /> Vi.Tank Info Capacity in Total P of Manufacturer <br /> Gallons Gallons Units ,� -1:1 .� <br /> New Tanks Existing Tanks .� c "� <br /> 1 U . rn w"c7 a, <br /> Septic or Holding T a n k 1 c 50 I tp50 M b i - v <br /> Dosing Chamber 8 0 - k _ NW A4)(` <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 /> — <br /> Andrew W Melnhol2 I . -L t...), ...-----6 220185 808-831-8103 <br /> Plumber's Address(Street,City,Stato,Zip Code) - <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Lssuin •g ..r.� <br /> Approved ❑Disapproved $ ��i!� :� <br /> ❑Owner Given Reason for Denial / 2 V ' .,3 �0---- -_• ' millerar' a <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 r/2 x 11 Inches in site <br /> SBD-6398(R. 11/11) <br />