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608-831-8107 MEINHOLZ EXCAVATING 240 P02 MAY 07 '09 10:09 <br /> sv,,,„ise 201 W.■Washington Ave., P.O. Box 7102 �!n w • <br /> • <br /> ( 1 12009 t4/761(.18W1) 53707-7162 Sanitary Permit Number(to be filled in by Co.)Department of_ ' met'��' 266-3151 <br /> 51 8.2 7`l <br /> iiPee i •� p� dtloll State Plan I.D.Number <br /> In accord 1th Co ,cr q,,� rsonai information you provide <br /> r►%�t1��gl s , f� uy-laat,s1S.04(1Xm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name ('jarnp'l CO-4 Row '� (� <br /> Property Location <br /> lit-41.1 L.v. al D.—Se— A1bltsyl-S <br /> kiE Property Owner's Mailing Address '/. Section -3'1 <br /> '724 A(d(o Ltcpdd <br /> I. T S N R E <br /> City State Zip I Telephone Parcel p <br /> k' Ic-tcwl, i I W 1 15 ,,2 II otac:38-314- 00047.0 <br /> of Building (Check all that apply) Subdivsion Name/CSM# Lot# - <br /> ) rPel or 2 Family Dwelling-Number of bedrooms '4 <br /> O Public/Cotnmercial-Describe Use ►'1d rl G <br /> O City 0 Village A Township of <br /> ❑ State Owned-Describe Use <br /> • <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)eyd <br /> A. >New System ❑Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System <br /> B. 1 O Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> [Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil 0 At-Grade ❑Single Pass Sand Filter <br /> 0 Constructed Wetland ❑Pressurized In-Ground 0 Holding Tank ❑Peat Filter 0 Aerobic Treatment Unit 0 Recirculating Sand Filter <br /> O Recirculating Synthetic Media Filter Cl Leaching Chamber ❑Drip Line ❑Gravel-less Pipe 0 Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Appl Rate(gpdsl) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> (DUO .4 15 DO 15(2 1C@A=—Mo.81 <br /> VI.Tank Info Capacity in .. Total No. Menu acturer Prefab Site Steel Fiber pia_ <br /> Gallons Gallons of Concr Con- Glass <br /> New Existing Units street St1C <br /> Tanks Tanks <br /> septic vilel/ing Tank- ,128t, -- 128 rd <br /> I Mve x <br /> Aerobic Treatment Unit ' <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature il4P/MPRSW No <br /> 4'Wtw.1 hl. MGr.hG12- _.--4,,(__ co.---)-\,_ 22C'105 <br /> Plumber's Address(Street.City,State.Zip Code Phone Number(Daytime) • <br /> 4815 cT . e irvAU r∎Akt.c, W k 599-7 2331. 0103 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Sanitary Permit Fee(incl Date Issued Issuing t Signature(No Stamps) <br /> ❑Owner Given W Surcharge Fee) q <br /> Reason for Denial 4L S- / e '�J /�� �G.ISi�� <br /> IX.Conditions of Approval/Reasons for Disapproval / <br /> IN VIR„NMING THIS APPROVAL.DANE COUNTY <br /> ENVIRONMENTAL HEALTH DOES NOT HOLD <br /> LIABLE FOR ANY DEFECTS IN P <br /> TIONS,PLAN OMISSIONS.E LAMS OR SPEC F CA <br /> SIGHT,CONSTRUCTION ' M1NAT1ON <br /> RESULT IN OR AFTER Ny DAMAGE TER <br /> TME RIGHT TG .it INSTALLA�,T,ION AN HAT MA. <br /> Attach complete plans 00 the County only)for the system on 1�ge •,,i ii�NS OR <br /> ADDITIONS <br /> SRJt; <br /> P6 — g.ttgo� n NECESSARY. MAKING THIS <br /> SBD-63911(R.01/03) �'f , <br /> Chk�- 14%64 - 4345400 <br />