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.,uuta.y <br /> Safety and Buildings Division Dane TM <br /> '1 <br /> i B, . = 201 W.Washington Ave.,P.o-Box 7162 Sonnet),Permit Number(to be filled in by Co_) <br /> psi Madison,WI 53707-7162 <br /> 33-2-o►b— ooly <br /> + State Transaction Number <br /> Sanitary Permit Application <br /> U accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental twit <br /> is required prior to obtaining a sanitary permit.Nom Application forms for state-mtaed POWlS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies.Personal information yptl srre ySe�fgrEsop - C t- 'r <br /> pm-poses in accordance with the Privacy Law,s_1594(1)(m)_Slats K{L•_� !\V/t'(,Jl l- 1 H "t 5 e r <br /> • I.Application Information-Please Print All Information <br /> Property Owner's Name <br /> 1CdC 44 I PP E-R c LA R_Tt-1 MAY 271816 �G•7- 0(0.2.- .2.140-0 <br /> Property Owner's Mailing Address }� pyt Property Location <br /> a2 I is S D AV IS �l1.1,5 V R1V nyitorunerstall Health Gn.t.Lot / <br /> City,State Zip Code Phone Number Ii 1/4`/. S W r/, Section 69 <br /> Ve-KONA La( 93 T GP N; R 7 E <br /> II.Type of Building(check all that apply) 4 • Lot: kV <br /> �lor2FamiyDwelling-Number of Bedrooms 4 1 Subdivision Name <br /> I Block d <br /> i DPnblic/Commcrcial-Descrile Use <br /> ❑--tt City of <br /> 0State Owned-Describe Use CSM N 0 Village of <br /> l I o2 EiTownof SpP i,u o A LE <br /> III.Type of Permit;(Check only one bat on line A.Complete line B if applicable) <br /> gfNew System r 0 Replacement System 0Treamrentflloldiog Tank Replacement Only OOther Modification to Existing System(e plain) <br /> i, B. OPemtitRenewal 0 Permit Revision OChangeofPhmmber DPermitTransfvtoNew <br /> Liss Previous Permit Ntmtberard Date Issued <br /> Before Expiration Owner <br /> IV.Type afPOWTS System/ComponcntfDeviee: (Check all that apply) <br /> ['Non-Pressurized In-Ground ['Pressurized to-Ground _Grade OMormd a-24 in.-"oof'fsuitable soil ❑Mound<24 in_of suitable soil <br /> OHolding Tank 00ther Disposal Component(explain) 0Preurannent Device(e plain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(Rdsf) Dispersal Arm Required(sit) I Dispersal AreaProposed(s0) System Elevation <br /> C oo , L y /064 /,3-m cp y SETATSIrE <br /> Total S of Manufacturer <br /> VL Tank Info Capacity 1° ota - =z <br /> Gallons Gallons Units B rj p - <br /> NcwTrmis Existing Tants c`.U ¢u Si E O e- <br /> Septic or BOtdmaTk /Zfj'(o ( ,' tote- koE <br /> °nsinQ G 50 I(v50 I I A-DE <br /> VII.Responsibility Statement-I,the undersigned,assume rrsponsiMTity foriustilatioa of the POWIS shown an the stbebed plans. <br /> Plumber's Name(Print) Plumber's Si mratue / MPIMPRS Number Business Phone Number <br /> Andrew W Meinhol (/v, Y�/� ' •.. 608-831-8103 <br /> Plumbers Address(Sheet,City.State,Zip Code) U _ ._ . <br /> 6813 County Highway K,Waunakee WI 53597 ..- / , <br /> VIII County/Department Use Only �'��', �'1/II <br /> 1.-Moved ❑Disapproved Permit Fee / .ri_'. <br /> S 1,)-q 51s <br /> i ❑Owner Given Reasonf�Denial f' 1 <br /> IX Conditions of ApprwvahReasons for Disapproval <br /> i • <br /> onaortor• '"?7am for tteminemaad submi%the Caress war m 1o5er not tea rhea alit ell:nthrsinsime <br /> SBD-6398(R.11(11) <br /> 1 <br /> I <br /> I <br /> 'i <br />