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-,; ., County <br /> Safety and Buildings Division Dane <br /> z? 11 _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> 'S P S = Madison,WI 53707-7162 <br /> °. 13 •201 o 0041--7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Notes 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 n� -/ <br /> purposes maCOnf�with the Privay Law,s.15.04(1Xm),Stats. rs�,(.1UMlt! PONI) T.A(L <br /> I.Application Information-Please Print AD Information <br /> Property Owner's Name # r <br /> {��'�k l 0 tnunicigAz . 61 0508-3IZ- 202.4-0 <br /> Property Owners Mailing Address Property Location <br /> 1105 iiJ i nit C 1 nitii .\1 J y Govt.Lot <br /> City,State '. T rp Code PhaneNmnba 14. a y ik a y.,Section 3 I <br /> t DDL€1DiJ UV I 5346,2 T 3 N; R 8 E <br /> II.Type of Badding(check all that apply) ! Lot# <br /> 5 P 14 Subdivision Name <br /> ®1 or2FamlyDwdl)ng-Number ofBrdrooms M-4T r(Mn1 '0�D <br /> Block# <br /> ❑Publiatommercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use ®Toenof SPRIWr1FttLb <br /> M.Type of Permit (Check only one box on fine A.Complete line B if applicable) <br /> A- ©New System ❑Replacement System ❑Treat rentfHolding Tank Replacement Only ❑Otheer Modification to Existing System(explain) <br /> e of Plumber amok Transfer to New List Previous Permit Number and Date Issued <br /> R. ❑Permit Renewal ❑Permit Revision ❑Chang <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-PrtssurimdtIn-Ground ['Pressurized In-Ground at-Grade ❑Mound>24 in.olf�suitable sol 0Mound<24 n.of suitable soil <br /> ❑Holding Tank ❑other Dispersal Component(explain) DPrcvmmrent Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) I Dispersal Area Proposed(sf) System Elevation <br /> 150 I /97S /b75 9G-4, r 97 Y' <br /> VL Tank Info Capacity in Total #of Manufacturer u <br /> Gallons Gallons Units 0 >? u P. - <br /> Na Teaks Existing T>� a U in 2 aoi F.V e. <br /> ` <br /> Septic err Holding Tank l L Ci 0 1450 -2, M€4)E X <br /> Dosing Chamber _ — <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on tbe attscred plans. <br /> Plumbers Name(Print) Plumber's Signature — l MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz I �— l..t.' �`-� ) 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) ���jjj <br /> 6813 County Highway K Waunakee WI 53597 <br /> VIII.County/Department Use Only Date Issued issuing A Signature <br /> ❑Approved ❑Disapproved Penns_ ;pee -. / <br /> ❑Owner Given Reason for Denial s!7/ C 3 j1+1��Cl.cti . -•' <br /> IX.Conditions of Appr ovaVReasons for Disapproval <br /> Attach to oaplete plans for die system and submit to the County only an paper rimless than S 1R s 11 inches is size <br /> SBD-6398(R.11/11) <br /> i <br /> i <br /> e,t.;..-sdia{n <br />