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/ �reri !i • ( it;_I ^'f t�'�� �y and Buildlllgs maim Cam, <br /> Dane. <br /> ir, g P �,� 1 i 201 Millington Ave.,P.O.Box 7182 Sanitary Permit Number(to be elks in by Co.) <br /> Pi ) l i son,WI 53707 7182 <br /> ` /" i DEC Q EC 1 3 2013 <br /> `.-4iaaiw i �, �� -moo/� r D�cg l <br /> S 1�et ti nnlication State tiremtictionNumber <br /> In accordance with SPS 3 ,.. r. rr �np <br /> is �to ?1f���%Wb:lr`cde;wdarisClbis to the appropriate governmental unit <br /> obeanirg a sanitary permit. Nolo:Application forms for star.owned POWf3 are submitted to 'Project Address(if different than mailing address) <br /> the Department of Safety and Professional Sarkis. Personal intimation you provide may be used for woodsy <br /> purposes in atOrdance with the Privacy Law,s.13.04(IXm),Slots. /.nn.g4el / c.a <br /> _I. Application Information—Please Print MI Information <br /> Properly Owner's Nano Parcel It <br /> .,J"1/./tc.. i' %.S4.// �l a-7/i- 033-- gi3o— 8 <br /> Property Owner's Mailing Address / Property Location <br /> 917 /-1,‘,,,,:-,574n„ a: vt. Govt.Lot <br /> City,SSiete Zip Code Phone Number <br /> ..1164..•..•for'i W .S37/ N� '/•,eSeu '/..section 3 <br /> IL Type of Building(check all that apply) / tat d T 7 N; R // E <br /> t1 or 2 Purity Dweliiag—Number of Bedrooms 7 3 Subdivision Name <br /> Block N <br /> ❑PublidCommerelal—Describe Use Dalyor <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> O 3/0 p ISITovnt of CoAVG. (c oVZ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1New System D Replacement System ElTrcarmartiliolding Tank Replacement Only ['Other Modification to balding System(explain) <br /> V. Befogs Expiration ❑Permit Revision ❑Cheage of Plwnbcr permit Transfix to New ' Permit Number and Darts Issued <br /> IV Type of POWI'S SystemlComponent/Deviee: (Check ell that apply) <br /> Noe-PresswiaedlIn�Ghound DPressuriaed In Ground 134t-Grade DMocnd 224 In.ofsuilabiasoil QMound<24 in.of suitable soil <br /> /❑_Holding Tank DOtaer Dispersal Component(explain) Device(explain) <br /> V.DitpersaVPrreatmentArea Information: <br /> Dui*Plow(Epo) Design Soil Application Rahn ripens!Area Required(st) I Dispersal Ara Proposed(at) System Elevation <br /> VI.Tank Info Capacity in Total Nor Manu ictruer <br /> Gallons Gallons Units 1 A I I M i <br /> New Talks Hwirtiaa7aolu <br /> Serde or Nola'Task 428C /0/5 6 a ...A4eae..1._ 10 <br /> Dosing Climber ,5a 65o / L <br /> VII.Reaponalbility Statement-1,the undersigned,mum responsibility fbr Installanoe of the POWI S shown on the attached plans. <br /> Plumber's Name(Print) Plumbers Signature MPMPRS Number Busies Phone Number <br /> Andrew W Meinholz _ w -71-7 220165 J 808-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> _ill <br /> VIII.Countr/Department the Only D Dimpproved Perrm�it Pee ' ,°"° 13 13❑ownerevenRaeoaforDalai !31• I s.. - <br /> DL Conditions of ApprovalfReasons for Disapproval <br /> A t t a c h toanpkteplus e r r s doe tube*se theCowry may ea immoralku tbaa a to all lofts lo ski <br /> Chi—' 654?4q <br /> q <br /> 5801095(R.11111) <br />