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County <br /> fr <br /> Safety and Buildings Division Dane <br /> ' ,D g P 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by o.) <br /> S Madison,WI 53707-7162 1 ,5-2.6110 -ran q <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 CA <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. S i1&I g L o$Sofut <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> jefri<E`1 4,44 1), KAITLY N KOKcI-r-r ()bob- 31z- 2134 - a <br /> Property Owner's Mailing Address Property Location <br /> '1st JVul\1 WOOD DR-iV>✓ Govt.Lot <br /> City,State Zip Code Phone Number , <br /> Ve i20N A. `N 1 535 9 3 cal\t4i, NW rigse section 3 <br /> II.Type of Building T e N; R S E <br /> yp g(check all that apply) Lot# <br /> 141or2 Family Dwelling—Number ofBedrooms 5 cps.4 Subdivision Name <br /> Block# AL-TUM ki PO b <br /> QPublic/Commcrcial-Describe <br /> 0 City of <br /> ❑State Owned-•Describe Use CSM Number 0 Village of <br /> APR 27 1016 EgTown of Sett.,i,t,i,(nc(,FJ .D <br /> M.Type of Permit: (Check only onatt ppekic pllo(Complete line B if applicable) <br /> ❑Re {� � to <br /> A. System Treatment/Holding Tank Replacement Only <br /> '❑Other Modification to Existing System(explain) <br /> B- ❑Permit Renewal ❑Permit Revision �-�t,_ List Previous Permit Number and Date Issued <br /> ❑Change of Plumber t_lNetmit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Zr-Non-Pressurized In-Ground DPressurized In-Ground QAt-Grade ❑Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> IDHolding Tank 00ther Dispersal Component(explain) OPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow//(11g��pd) Design Soil Application Rate(gpdsf) Dispersal Area}Required(sf) Dispersal Area Proposed(si)) System Elevation p r <br /> rt 6 0 / t ..r /42 i ,5— `" /4:7. <br /> I ,4,:Y ✓ 96.41 e 6.3'a_s (J....!• t <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units .e. 5 E 13 o <br /> v4 c 2 `v u a New Tanks Existing Tanks 0 o 2 4., s a <br /> c_U in h to i C; c <br /> Septic or Holding Tank 1 r_C Q / 1 µE.AD G <br /> Dosing Chamber i9;.7 G- <br /> VIL 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 it.) 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 Perm Date Issued Issuing__• • i l••tore Ar.... <br /> 0 Owner Given Reason for Denial $` t 11/Z8//6 41;,, <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 all inches in size <br /> SBD-6398(R.11/11) <br />