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County <br /> Safety and Buildings Division <br /> Dane <br /> •):` n . 201 W.Washin on Ave. P.O.Box 7162 D Sanitary Permit Number(to be filled in by Co.) t„ <br /> S„ Madisot � E�2�E <br /> ' S / 3- 2 'U -Gl) D <br /> MAR 17 ZOt6 <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appblivitdamMtelttlIatital unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for statErtyleetffiaktil spkrgilfetlito Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary D�j <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stets. 5 t j, 2 ! t`�L v C <br /> I, Application Information—Please Print All Information <br /> Property Owner's Name Parcel II <br /> E,ILi 1 3() CKAt6, EmCns-rieD 1 or7d5_ (94.- 6 ot 2.- 1 <br /> Property Owner's Mailing Address Property Location <br /> 410 Aft.AeLe.S(!PE_ L)giv Govt.Lot p <br /> City,State , ' Zip Code Phone Number Se. v, SE vs, Section I J <br /> �AOlsOr\ ` <br /> l WJ I 537I 9 T 47 N; R a E <br /> II.Type of Building(check all that apply) Lot n <br /> NI2 Subdivision Name <br /> or2 Family Dwelling-Number of Redroome SAu — Q0t&II P‹-'rATssS <br /> Block;/ J r <br /> DPublic/Commercial—Describe Use ❑City of <br /> CSrN1 Number ❑Village of <br /> OState Owned—Describe Use Town of N t Q ID L 1— /\ <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. rut System 1:::1 Replacement System ❑TreatmentIHoldingTank Replacement Only ['Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. El Pernik Pe Renewal ❑Permit Revision ['Change of Plumber QPermit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized in-Grourlg/ ['Pressurized in-Ground ['At-Grade ['Mound?24 in.of suitable soil ['Mound<24 is of suitable soil <br /> [3 bIding Tank QOther Dispersal Component(explain) <br /> Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Informatior.: Dispersal Area Proposed s System Elevation <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) { p (1) y / ,� <br /> GI 00,,• `� / J`1 93.9, '74.T, 74/.7 <br /> Capacity in Total If of Manufacturer j 6• <br /> VI.Tank Info _ o <br /> Gallons Gallons Units -2 U n .= <br /> W C r 2 J s <br /> New Tants ^3eistin_Tanks a.V tr -i m t_U C- <br /> Septic or Holding Tank + Ig '( �� i <br /> Dosing Chamber Soo o' 0410 I ,� > - <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation or the Pawl's s o �Number attached ached plans. <br /> ss Phone Number <br /> Plumber's Name(Print) Plumber's Signature <br /> Andrew W Meinholz _ L.A..., , 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Permit/Fee Dale Issued Issuing A'entSigna e <br /> El Approved ❑Disapproved k4 <br /> 0 Owner Given Reason for Denial $ Y-11 03 f o/r i C / •// <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 loss than a 712 x lr inches in size <br /> SBD-6398(R-11/11) <br />