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• <br /> r <br /> '4'- <br /> -..:n+;.. County <br /> Safety and Buildings Division Dane <br /> \D S 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P 3 ` Madison,WI 53707 7162 <br /> :f 13.-tot b- (200??'. <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 fo o t fitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal inform vi ndary <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm),Stats. y EU4. RGA D <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name APR 1 6 2016 Parcel# <br /> AYMt3tALiCE POMP 1110 Cie,iI — IZh - 1i5..: -- C; <br /> p,,611c Health MDC <br /> Property Owner's Mailing Address Property Location <br /> 1 Environmental Health <br /> 5�'i3FJ eli2M_;SLHtJi) 1 E-IZtZA('�_ -. Govt.Lot <br /> City,State Zip Code Phone Number <br /> i ,/J 1 p uJ t'A, SvI 'A, Seetion j, <br /> 'YiPcKSi-1ALL ,E_�_ T <br /> �7 i T ?) N; R i E <br /> IL Type of Building(check all that apply) Lot if <br /> igI or 2 Family Dwelling-Number of Bedrooms i 5 Subdivision Name i / <br /> Block# S A V A IV:V/#N V A L I—F-`f <br /> ❑Public/Commercial-Describe Use ['City of <br /> CSM Number ❑Village of <br /> OState Owned-Describe Use �}.— <br /> [ Town of SIAN P rLA1 Rt e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1'New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only QOther Modification to Existing System(explain) <br /> B. ❑Chan List Previous Permit Number and Date Issued <br /> ❑Permit Renewal ❑Permit Revision Change of Plumber Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground QAt-Grade Mound 24 in.of suitable soil Mound<24 in.of suitable soil <br /> Holding Tank Other Dispersal Component(explain) TTT���"' Qpretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(si) System Elevation C s <br /> U_O0 .- ? . / G `-'-'f" . c,_-;ET AT i-16-- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 0 o. b y <br /> New Tanks Existing Tanks o 2 u°- 9. <br /> 0 <br /> Septic orfloMing Tank t Ur(P _- i aa, "Z' ` E A D E . <br /> Dosing Chamber is SO _ LC)O ( ME AO c 74" , <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 1 MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz - - t') • "7"`i7 --�-�I 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 /> Permit Fee Date Issued Issuinn Agept Sintature ,; <br /> Approved ❑Disapproved $ ` . <br /> ❑Owner Given Reason for Denial , : / <br /> IX.Conditions of Approval/Reasons for Disapproval E <br /> _.✓i , ra,ti-,` :�.� 7 �.r �i� �,!',7j..�: ,911"-..-f"`, <br /> J i, /v! i .;--/l-' !✓\ ice' ` n ,-i.,^/,'l _._,-, 'rr,—!l <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x11 inches in size <br /> SBD-6398(R.11/1 1) <br />