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County <br /> Safety and Buildings Division Dane <br /> I)S 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by o. 1 <br /> P a Madison,WI 53707-7162 0(10-0WCII 0 <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 /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. r'l p (J7 f 'L.O 300`,n Co L R•I. Application Information—Please Print All Information "t <br /> Property Owner's Name Parcel# <br /> f A(C_!4RLU CLA Sc-i.1 080F) - 5f2- - 2_1Ei`'1 ° G <br /> Property Owner's Mailing Address Property Location <br /> I-7955 AL1J1oPE DRIVE Govt.Lot <br /> City,�/Sttatte n 1 r Zip Code ) Phone Number J�)`/i n' I <br /> v t--�U�Nt Yv ` 5ti7 E-3- c-) 3 1�W11 '/a, IV�1� '/a�SecliEn <br /> T 0 N; R <br /> II.Type of Building(check all that apply) Lot# <br /> N.l or 2 Family Dwelling—Number of Bedrooms <br /> / 2,`) Subdivision Name <br /> Block# ALAILA POND❑Public/Commercial—Describe <br /> CEIVED <br /> ❑City of <br /> ❑Slate Owned—Describe Use APR 2 7 2016 CSM Number ❑Village of <br /> (2 Town of GpK(,m_6'Tc--l.fz-t t7 <br /> Public lioalttt MDC <br /> HI.Type of Permit: (Check onlEmktuatiflagalMlegalete line B if applicable) <br /> A. 87f New System e ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B ,/ List Previous Permit Number and Date Issued <br /> ❑Permit Renewal ❑Permit Revision ❑Change of Plumber FlPermit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> gfNon-PressurizedIn-Ground/❑PressurizedIn-Ground [It-Grade 0 Mound 24 in of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank 00ther Dispersal Component(explain) Pretreatment Device(explain) <br /> V.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation , <br /> (.Q00 r `-f / l5GO l5 l Z ✓ loa.o/ 9/.0 , 9(,.5' <br /> VI.Tank Info Capacity in Total #of Manufacturer cr <br /> Gallons Gallons Units o z <br /> vy <br /> New Tanks Existing Tanks L o y 2 -0 ° rs <br /> r e.U co H 01 c:. 3 F. <br /> Septic or Holding Tank 'c9- 61 G, / 6J� � at 1, D.G <br /> Dosing Chamber ($ s o f &50 I EPCoE ` <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 ' — - 220165 608-831-8103 <br /> �7- - L-) <br /> Plumber's Address(Street,City,State,Zip Code) `' <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Pe Date Issued issuin ignaturt: <br /> 0 Approved 0 Disapproved $ N/ <br /> 0 Owner Given Reason for Denial Zd/�(� J .11�I e�`�, <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 8 112 x t l inches in size <br /> SBD-6398(R. 11111) <br />