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County <br /> Safety and Buildings Division Dane <br /> D 201 W.Washington Ave., P.O. Box 7162 �� <br /> $P S <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Number(to be filled in by Co.) <br /> .,•,,,- 13-20i ,- Coo Li', <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 POWTS are submitted to Project Address(if different than mailing address) <br /> the ores accordance of Safety and the Priay Professional Law,s.1s. Personal(1)(m) information ats REiCPurposes in accordance with the Privacy Law,s. 15.04(1 xm�Stars. IC..11 J F`-•IL!)' Q Sat) L Ai-Ni E <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> A-A-zol..) AND LALL ..A SCHALi te_ MAR 171016 09I( — (94 - 95(07-- 0 <br /> Property Location <br /> Property Owner's Mailing Address Public Health MDC Pro ` <br /> 3 o 3 i tat t l)N I(nt-tr G u k) Environmental Health Govt.Lot <br /> City,State Zip Code Phone Number <br /> s J 1/4, 5 E '/., Section (9 <br /> SuNi PlkAtR. tt: kAt( 535,0 T 9 N; R ( ( E <br /> II.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling—Number of Bedrooms 1 Subdivision Name /{ <br /> Block# LE(-(-NI.A-N'S AD0t1-20L) <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> Town of g P.,I STO L- <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A {New System IlJ y El Replacement System ❑Trratment/Flolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Chan a of Plumber List Previous Permit Number and Date Issued <br /> g �ermit Transfer to New <br /> Before Expiration Owner <br /> • <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground QPressurized In-Ground OM-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank IiiiGther Dispersal Component(explain) £Z r-L.( -J OPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: U.,/ <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation i <br /> 150 . `/ / ° 1,.-S c u t> 9. ;z,'9i.6 9/./ yc y .° <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o o d <br /> New Tanks Existing Tanks u o u 2 �n ,o 'a <br /> o, U w h rn iz v G <br /> Septic orHotding Tank ((_Sam, y t/ _Q© "2 -�e. . . <br /> Dosing Chamber 800 ✓ IL�J ) _ E koe J✓` <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 —'1- / 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuin gent <br /> ❑Owner Given Reason for Denial $y:/" 3-f 8-za/ 24/01/('\) - <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 12 x 11 inches in size <br /> SBD-6398(R. 11/11) <br />