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L_ �,.xn i: r County 4 <br /> Safety and Buildings Division DAIN d, <br /> Da- - ay 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in gi -\.)5 ci, rL'" <br /> Madison,WI 53707-7162 <br /> S '! b <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 <br /> i purposes in accordance with the Privacy Law,s. 15.04(1)(m).Slats. e/ � 1 V fj <br /> I. Application Information-Please Print All Information Ail f ey <br /> /V) <br /> Property Owner's Name Parcel# j <br /> R rJA �s t/4.4 /e <br /> e.N 13 01 -41A V --'-87a <br /> ,t - a);- Yo;o -a <br /> Property Owner's Mailing Address . Property Location <br /> 2 C �. " /'`4 DI " -R d. Govt.Lot <br /> City,State Zip Code Phone Number <br /> 4,/,,4,/,,5-4) /. /Jl 441 /, Section 3/ <br /> /Va�r SS� �� �� � <br /> 3 circle ne) <br /> H.Type of Building(check all that apply) Lot a T N; R ( Jr W <br /> j ,or 2 Family Dwelling-Number of Bedroo s / Subdivision Name l • (/ <br /> j Block# '!4'/! Y O il <br /> .�Public/Commercial-Describe Use <br /> 0 City of <br /> U State Owned-Describe Use CSM Number ❑ Village of <br /> ?Town of mi dd j r°;-p/t/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> System' A. I. 'flew S <br /> Y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> f <br /> B- i 0 Permit Renewal 0 Permit Revision U Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> • l Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground U Pressurized In-Ground U At-Grade tdP...und>24 in.of suitable soil U Mound<24 in.of suitable soil <br /> U Holding Tank 0 Other Dispersal Component(explain) U Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) ` Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 4 cc>. I fl, t. /aacs is/i 103,7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units = <br /> a :? ) u <br /> New Tanks Existing Tanks ,s = . H <br /> c v v v n <br /> Septic or Holding Tank `0 p4 /07 R4 ) <br /> Dosing Chamber / t? ��,. s <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 Awignature —/ MP/MPRS Number <br /> KENNETH MEIER / 224144 <br /> (,C_— � . 608-849-8771 <br /> Plumber's Address(Street.City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> 1 <br /> 1 VIII.County/Department Use Only ----- - <br /> I'4pproved U Disapproved <br /> Permit Fee ^ Date Issued IssuJ g Agent-;;,;.L.,..- <br /> 0 Owner Given Reason for Denial S 1 /t(J ' :L f <br /> IX.Conditions of Approval/Reasons for Disapproval �� ��� <br /> l <br /> attach to complete plans for the system and submit to the County only on I <br /> ty y paper not less than 8 nR x II inches in size <br /> SBD-6398(R. 11/111 <br />