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.. County <br /> Safety and Buildings Division Dane !<- <br /> z~`D S 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.)' <br /> p S _ Madison,WI 53707-7162 <br /> Sanitary Permit Application Stare Transaction Number <br /> In accordance with SPS 38'.x21(2),Wit.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(I)(m),Stns. 0 SLO L fk N c <br /> 1.Application Information-Please Print AB Information <br /> Property Owner's Name Parcel# <br /> PAULSO�i D*VaopIteie(\LT t.i.E. (C/0 A'MglANiCE '1Es ituc - 09i1 - (94-4Cl- C <br /> Property Owner's Mailing Address Property Location <br /> 5835 &lrzPtss tiO "T ZAc.E Govt Lot !!Q <br /> City,State Zip Codc Phone Number .. S t j tI SE, 'A,Section (/ <br /> KA, SI-+-Flee-- (A.1( 535 5> T 9 N: R I t E <br /> II.Type of Building(check all that apply) Lot a <br /> &1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block: I.g&4-MAN'5 A-DOi TIC 4 <br /> ❑PubliclCommercial-Describe Use D City of <br /> ❑State Owned-Describe Use CSM Number ❑}Village of <br /> r Town of el(ZAjTtJL <br /> III.Type of Permit: (Check only one box on line A_Complete tine B if applicable) <br /> A. New System D Replacement System ❑Treatment)lolling Tank Replaceme t Only DOthcr Modification to Existing System(explain)tgi <br /> B kR <br /> B. ❑Permit Renewal 0 Permit Revision ❑Change of Plumber LJrermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Cheek all that apply) <br /> ❑Non-Pressurized Ian-)Ground DPressurized In-Ground DA 77�����` <br /> at-Grade Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> D Holding Tank DOther Dispersal Component(explain) DPue►cuu,,ut Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Raie(epdst) m Dispersal Area Required(sf) r Dispersal Area Proposed(sf) System Elevation <br /> U 00 - ,.4- l//7o a - ///47 S F.T-/r'r S era <br /> VI.Tank Info Capacity in Total S of Manufacturer , g <br /> Gallons Gallons Units , `v J 3 u <br /> New Tanks Existing Tanks ., g 2 2 y <br /> �j =/U in w rr, -3 <br /> Septic erilolding Tank I y1 bid, i d-s q -i� u jc e7 E �1 <br /> Doing Chamber t1Q r C) ,-- LSO t nn. D �C <br /> VII.Responsibility Statement-lI,,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 ..'1- tA.A , 220165 608-831-8103 <br /> Number's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only tA3/j <br /> Approved ❑Disapproved Permit Fee Date.Issued h,k� rl^! ,� <br /> Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval r- <br /> I <br /> Attach to complete plats for are system and submit to the County ady on paper net tour than a us a 11 inches in use <br /> SBD-6398(R.11/11) <br />