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County <br /> Safety and Buildings Division Dane (3A1, <br /> t " D S , 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI 53707-7162 <br /> 13.211 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 ��e}p Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information o a d �"I�,J•,1 <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm),Stets. S A <br /> I.Application Information-Please Print All Information MAR 1'/ 2U16 T <br /> Property Owner's Name Parcel# <br /> `A-L 1'1" 3 L—('E CLOSE Public Health MDC 0700- 043-4 (0'7-0 <br /> Property Owner's Mailing Address Environmental Health Property Location <br /> 1734c) SUMMIT R.toG,E- Ro co Govt.Lot <br /> City,State Zip Code Phone Number 5 t OIL l Ufa ( 535(0Z « 1/4,SW '/' Section <br /> T I <br /> U.Type of Building(check all that apply) 1 Lot# <br /> N: R S <br /> or2 Family Dwelling-Number ofBedrooms 1 (87 Subdivision Name <br /> Block# V.t t44 PE t it4 n \AJ( L)S <br /> ❑Public,Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use <br /> fit CSM Number f❑Village of <br /> I Town of t1/t t 1�OL F7-04 <br /> III.Type of Permit: (Check only one box on line A.Complete line B if applicable) <br /> A' ❑New System ®Replacement S Only❑Treatment/Holdin Replacement Tank lacement tp y ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber t_yerm it Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ID Non-Pressurized In-Ground ❑Pressurized In-Ground 0At-Grade 0Mound>24 in.of suitable soil ['Mound<24 in.of suitable soil <br /> ❑Holding Tank Other Dispersal Component(explain) Z.ci.C)Vj „- ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation 91.3 r�O,(t <br /> ( 0 D ✓ '- `S°D '” I SSLk <br /> VI.Tank Info Capacity in Total #of Manufacturer , <br /> Gallons Gallons Units m o'O <br /> New Tanks Existing Tanks '- c u <br /> r. ° <br /> a`U in h <br /> Septic or Holding Tank t -' , �r1 e c7“4 <br /> Dosing Chamber <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 f MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz (� i(1 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 /> ❑Approved ❑Disapproved Permit Fee ,.Date Issued Issuin/� g Agxnt Sig'��2 //' ` ' <br /> ❑Owner Given Reason for Denial $2, f)3/Zy �A Vi i,/ i//�vj(/ <br /> IX.Conditions of Approval/Reasons for Disapproval / <br /> Attach to complete plans for the system and unbent t to the County only on paper not Into than 812 a 11 inches in size <br /> SBD-6398(R.11/11) <br />