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County ]�� <br /> •`iiTn4:•w7_I Dane <br /> -Ss: Safety and Buildings Division <br /> 1 :3•: 201 W.Washington Ave.,.P.O.Box 7162 Sanitary Permit Number(to be filled in by Co:) <br /> .$• $p . '= Madison,WI 53707-7162 ff/ 006 ‘( <br /> Stale Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 3832l(2) Wis.MM.Code,submisSion of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary pertntr,dote:.Application forms for state-owned POWTS are submitted to:-.Project Address tit-different than mailing address) <br /> the Department of aatbty and Prot-000W acy l _servies. Personal itrlbnnatio E E � �/ <br /> ptuposesinaccordance with the Privacy taw,s.i3.o4(1)(m),Stets. e tat/LA s i-t .n Al S 7 COt4(( i <br /> 1. A• )icatlbn Information–Please Print AU Information <br /> Pre I. y sNano MAR$11 i p cl$ <br /> .EC. MADi Ki 1-LC r a/v <br /> 0 , O - 4053 -0 <br /> • , - + , I, Property ovation <br /> Praliorty0t�ner'si�IniiiagAddnss E "nvironmental Health <br /> labC)i OLt,Th -frdvd A E b is,Ni Govt Lot <br /> City.S t a t e 'Lip Code Phone N weber iJ t/., 5t1 j V4, Section 24 <br /> MAD lid' ' - 1 T r7 .N_ R__5____E <br /> IL Type of Building(check all that apply) Lot d I <br /> f 3 Subd•ision Name <br /> g]or Family Dtvetlting-Number of Bedrooms t ,P RU. RCA-UM) <br /> Block n <br /> ❑public,Cornmere al—Describe Use ❑City of <br /> CSM Number -,❑Village of <br /> QState Owned-Describe Use %y <br /> []Towmof MiDi)L.1=t c>"I <br /> M.Type of Permit: (Cheek only one box on line A..-7 Complete line B if applicable) - r-t <br /> A. New System 0 Replacement System t:Treatment/H•Ioiding Tank Replacement Only fOthor Modification to Existing System(explain) <br /> ListPrevious PennitNumber and Date Issued <br /> B. ❑Permit Renewal El Permit Revision <br /> ❑Change of Plumber lJrCrtuitTraasferto New ` <br /> Before Fixation Owner <br /> IV.T •e of POWTS S stem/Com.onentlDevice: Check all tbata+,! <br /> • <br /> QNon-Pressurized In-Ground Opressurizeri In-Ground ❑.1t-Grade fi►: ound>24 in.of suitable soil tMound<24 it_of suitable soil <br /> ■[H Ei <br /> olding Tank Other Dispersal Component(explain) _ DPretrcatment Device(explain) <br /> V.Dispersal/Treatment Area Information: ( System Hlavatwn <br /> Design Flow(gpd) DasigaSold Application Ref t) Dispersal Area Required(SI) Dispersal Arco Proposed st) Sy S _� ( <br /> V.I.Tank Info Capacity in Total g of Manufacturer :` <br /> Gallons Gallons Units' <br /> V w K V <br /> Nc�: Existing Tanta t 5 g . i <br /> t d:'U to us.V <br /> semis or Holding Tank. i (XS 1en)r(f . Vat; +'.D 0 Y:''' <br /> Dosing Chamber (x:ra CJ GS L.: I. i AD it <br /> VII.Rea•onsibili, Statement—i,the endersi•nevi,assume responsibility for Instaftttion-of the P011TS shown on the Ached.,Inns- <br /> Plumber'r.Name(Pdnt) Plumber'aslenature MP 1• umber Business Phone Number <br /> AndrewW Meinholz _A-----‘— (►>. e-)- 220165 608-831-8103 <br /> Plumber's Address(Street City.Slate,Zip Code) <br /> 6813 County Highway 1<,Waunakee Wi 53597 4 <br /> VIII.Court IDe ailment Use Oat ( i, T+}ita` 1r�, <br /> Permit Foe., Date 1 Ism I ,� <br /> Itpprpved Disapproved S '� i , d��v'' <br /> D Owner Given Reason for Dania( � -A i* <br /> �.�1■�ea!w— . <br /> IX.Conditions of ApproxalIReasone for Disapproval '•' s • <br /> e <br /> Atlacb to complete picas for lbesystem sea snbttdt to tine Cheery anti on pup ern nit w thong to a 1.1 Indio io She <br /> MID-6398(R.11111) . <br />