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QQ LL <br /> j��- County f�.T) <br /> = Safety and Buildings Division Dane <br /> -e . $ SCANNED)I W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be fitted is by Co.) <br /> irk Madison,WI 53707-7162 . <br /> , � - - /3 - a-o,& - <br /> Sanie Permit Transaction Number <br /> Lary t Application State T <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary pemtit.Note:Application fonts for state-owned PUNTS 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 /> limpm'ts in acsoidane a with the Privacy Law,s.i�04(IXm),Slats. 0 s I C t ,a l ' E <br /> L Application Information—Please Print All Information N� 6 w/ t 4.-- lJ L./�4 N G. • <br /> Property Ovmer's Name P a�tZ A� ANLISA� YL. Z :M 10A*M-( A�f z E W O <br /> _ 0 <br /> Property°Vne'SMMailling Address ,8(2 'K` Property Location <br /> 5' r Af 6o6 of Iv <br /> 5-219 Govt_Lot <br /> City,State Zip Code CC Number SW '''A, SE v.,Section 19 <br /> Mustki i : \t j t 53 55-9 T 9 N; R._ 11 E <br /> IL Type of Building(check all hat apply) /� <br /> Lr <br /> 'or Family Dwelling—Number of Bedrooms "1 I 1 Subdivision Name <br /> Block# Ll✓64-MANPS ADDi'ic,#J <br /> DPubliclComme ial—Describe UR E C E I V E D D City of <br /> OState owned—Describe Use CSM Number D Village of <br /> MAY 2 7 2016 gown of 13 P-1 S T-0 t- <br /> Ili Type of permit» (Check only . , 'm, 1' ' •• '' ‘ , tineB if applicable) <br /> A. just System - <br /> ystem D Replacement System IN Treatment/Holding Tank Replacement Only DOther Modification to Existing System(explain) <br /> B. 0 Permit Renewal I:Permit Revision DChange of Plumber DPermitTransfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-PressurizedIn-Ground OPressurizedIn-Ground at-Grade OMound 2:24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> DHolding Tank DOther Dispersal Component(explain) ElPretreatinent Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gd) i Desig r Soil Application Rate(gdst) Dispersal Required(sf) Dispersal AreaProposed(5-1) System Elevation r <br /> ( 00 • y / � • I lsiz 147.2 9G,Si 95.8 <br /> VI.Tank Info Capacity in Total S of Manufacturer <br /> Gallons Gallons Units <br /> .0 2 Cj2. o <br /> New Tanks Existing Tanks ` c g 2 .5 c S. <br /> A:U U H m c.0 <br /> Septic milieu Tank 1.2-B GI — Ib ca M f AD E X , <br /> - <br /> i ie Chamber G 5 d `' 660 1 Nt.�A0 e x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the PONDS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz 11 _ I-0. 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Tap Code) —�T�°� <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII County/Department Use Only <br /> Approved ❑Disapproved <br /> Permit Fee 0o Date Issued IssuingAg p77t7 ��J��, <br /> ❑Owner Givexn Reason forDenial I3) ' 5'1?-20/6 c ��t�"vfr"1 <br /> IIL.Conditions of Amens for Disapproval <br /> 9t>a&totmmpiete?Was for tbesy stemaral submit to the Coast,out;an palter winless than 8tnx11 inches insia <br /> SBD-6398(R.11/11) <br />