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County <br /> Safety and Buildings Division Dane <br /> D$ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> '\ P S ti Madison,WI 53707-7162 <br /> -1.• 1 \s,15-/-2—(-)\. (0.—C/C)\-CH <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 P <br /> purposes in accordance with the Privacy Lave,s.i S.04(1)(m),Stats. �3 E L_r V t N Fes- CoeI& ,7 <br /> 1. A lication Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> 'MR,ec vt-1 AID 3of\J L-LC -' or7 v8 - Za3 -4C1 _ Q <br /> Property Owner's Mailing Address Property Property Location <br /> CJ <br /> (Q O 1 Sou Tow W F D�,t�r Govt:tot <br /> City,State Zip Code Phone Number "'' <br /> -'s V I v4 c� 1. 1 t/,,, Section ZO <br /> M t5-bisoNI w1 5 3-7r�;� �V <br /> T I N; R 3 E <br /> H.Type of Building(check all that apply) Lot# <br /> XI or 2 Family Dwelling—Number of Bedroom 5 l.' .9 9 Subdivision Name <br /> etocttx jP2tl G i-�'GI�t�JVJ <br /> ❑Public/Commercial—Describe Use —"''J�' <br /> O City of <br /> State Owned—Describe Use <br /> ECSM Number ❑{Village of <br /> Town of .\.A.(f01)Z.(�77-0 <br /> Y .•Type of Permit: (Check only one boa on tine A. Complete line B W applicable) <br /> A. <br /> ®New System Replacement System OTreatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. O Permit Renewal Permit Revision ❑Change of Plumber OPermit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1V.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground OAt-Grade pMound p 24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> OHolding Tank ❑Other Dispersal Component(explain) OPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: / I <br /> Design Flow(gpd) Design Soil Application Rate(gpds0 Dispersal Area Required(sf) Dispersal Area Proposed(s0 System Elevation r4� r40 <br /> ri 5 O . C /.25` ., 13/7 SET ,qtr-r I-re <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> G d J <br /> C CU V U ,fl G in <br /> New Tanks Existing Tanks o C <br /> e. U v: .1 to is 0 i1. <br /> Septic aril:eidingTank t C5p ,1� �, lae--1pE }�( <br /> Dosing Chamber t boo 6o0 k K,, -A4. is '` <br /> VII.Responsibility Statement'- 1I,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 .._....._. .'‘, '--N----- 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> t <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issui j7re <br /> A{iproved ❑ Disapproved S ➢ 5�'�3l 0 J` � je <br /> ❑Owner Given Reason for Denial 3 tl <br /> IX.Conditions of Approval/Reasons for Disapprov 1,6-7 te,y- cord-It- g 4.1919 <br /> --- A '4^40 P-1,070 ntvrr v 2-5 t <br /> ..--1. ' - 7 -7 010.0(e, st.17° n7� , ,4-4‹.4 (s— -� ' s'c p� r r�<L <br /> c 4,,, ,�0N s &Lc V*Y o ' (cJ L 74P 4 <br /> Attach to complete plans for lilt system and submit to the County only on paper not less than 8 tr2 i 1 t incises in size <br /> SBD-6398(R. 11/11) <br />