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County <br /> Safety and Buildings Division Dane <br /> r, `11 S `. 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,,, pS Madison,WI 53707-7162 <br /> 13- C ; 10- 00073 <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 Department of Safety and Professional Servies. Personal information you provide may be used for secondary LA purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 13 AY LA Lt t',et_ LA Ni E. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Yl K EC '/I-1 MA D i 5(;tA [-LC C r7c 0 ,- 2_03 - (a i 9 9 - o <br /> Property Owner's Mailing Address Property Location <br /> € 0 1 SOU fl-/ ( C7 kit.! NI t= DRt f E Govt.Lot <br /> City,State Zip Code Phone Number <br /> SE. t/4,Svi /4,t Section 2, ) <br /> VIA-Or So iJ VII 3 .7� _3 T ` i N; R , E <br /> II.Type of Building(check all that apply) Lot# <br /> M1 or Z Family Dwelling-Number of Bedrooms <br /> C)9 Subdivision Name <br /> Block# 5 PkL(.L.61 t-k'lL:-O tAf <br /> ❑Public/Commercial-Des+ {\e E C E I\f E D <br /> 1 .6 V Cit y of <br /> ❑State Owned-Describe Use CSlv1 Number ❑Village of <br /> APR 2 8 2016 ®Town of <br /> III.Type of Permit: (Che (oq air t�$f e . Complete line B if applicable) <br /> A. f�ifl@ <br /> New System Replacement System Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal [1 Permit Revision List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Cheek all that apply) <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground QAt-Grade OMound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank C.10ther Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(epdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation t �- <br /> rl 5 G . y /97 S. /. /4 7s.9 78.6, 7g), 7/ <br /> VI.Tank Info Capacity in Total #of Manufacturer It <br /> Gallons Gallons Units D B v g .i.) <br /> New Tanks Existing Tanks t g u 2 - iia rs <br /> L-U v: en i+ 0 c.. <br /> Septic ordrkriel,mg Tank 1 1.49 C f1i =— l 1_cO P LC (0 e <br /> Dosing Clamber t .0{0,� �' LIflac i 1\4 c.rA oe 1 <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 , , —. W `-,-• - 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 /> Permit Fee Date Issu Issui2nti (ge gn re <br /> Approved ❑Disapproved �° <br /> ❑Owner Given Reason for Denial 5 .,, 1, ' , vl() <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 trz x 17 inches in size <br /> SBD-6398(R. I1/11) <br />