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_, I County n t� <br /> I Safety and Buildings Division I Dane R r Tt <br /> _ - D J . 201 W.Washington Ave.,P-O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S _ <br /> Madison,WI 53707-7162 <br /> • � <br /> 1 State Transaction Number <br /> �an_tary Leri_1i%1�ppIicatio�? <br /> In accordance with SPS 33331(?),Wis.Adm.Cr'de,submission of this form to the appropriate govemmental unit <br /> is required prior to obtaining a sanitary permit. Nate.Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servie;- Personal information you provide may be used for secondary <br /> pusposm in accordance with the Pti-:acy Lax,s.3 C.4(:)(in),Slats. �A 'i v <br /> I.Application Information-PleasePrin;All'Information V Y A 'r ROAD <br /> Property Owner's Name Parcel 4 <br /> Roo £ l<AREtJ Ker(Z o9i1- 02,13- 9305 -0 <br /> i Property Owner's Mailing Address 1 15 Property Location <br /> 1-1 t L t..1 O P DRIVE Govt.Lot <br /> City,State I Zip Code ' Phone Number , t. <br /> Sons PRAIRIE W I 1 535902 SW ' �� ,Section 1 <br /> II.Type of Building(check all that apply; Lot 4 T 9 N; R .0 E <br /> ®I or 2 Family Dwelling-Number of Bedrooms 3 ( Subdivision Name <br /> R CE Block <br /> Q ���` <br /> Publie/Commotcial-Describe L'se`� D I ;--1�Cityaf <br /> ['State Owned-Describe Use SEP 2 8 2016 I CSM Number O Village of <br /> 14141 2 Town of B R I STO L <br /> r� public Health, <br /> TI).Type of Permit: (C'neelt onlvyr6RE11?aersek Complete litre B.if applicable) <br /> A' .New System ❑Replacement System Treamenr/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 0 E. _1 P rm it Renewal ❑Permit Revisic.t ❑Change of Plumber 0P.. it Traresferm New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T;/pee of?03VTS 5vstem/ComponentiDeva_e: (Check ealt that anoiv) <br /> ®Non-Pressurized In-Ground 0Pressurizec fn-Ground DAt-Grade ❑Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> 0 Holding Tank D0ther Dispersal Component(explain) QPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Sol Application Rate(gpdst) I Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevatign <br /> 1150 • `/ I //..7S- ` 11,22 1 97.r <br /> VI.Tank Info Caine:),in Total S of Manutcturer , s <br /> Gallons Gallons Units d 6 z —° <br /> r <br /> Neer Tanks Einsting Tanks ` n °2 - _ <br /> CJ u � r_ _ <br /> Z.cf./ v.t`n f I r=C _ <br /> 1 Senticartlaiding Tank 950/3ooI --- I105o t MeaOF_ x Ili <br /> 1 Dosing Chamber boo I (pO 0 11 me ape X <br /> VU.Responsibility Statement-(.the undersigned,assume responsibility for installation of the POSITS shown oa the attached plans. <br /> Plumber's Name(Print) Plumber's Signature /// MP/II/MRS Number Business Phone Number <br /> Andrew W Meinholz _A.-- , . _--_T 220165 608-831-8103 <br /> Plumber's Address(Sweet,City State,Zip Code) w\ <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VII.County/Department Use Only _ <br /> Permit Fee -Date Issued Issuing Age t fir.k.pproved ❑Disapproved S r <br /> ❑Owner Given Reason for Denial t 1 1 Jul—296 <br /> IX.Conditions of Approval/Reasons for Disapproval n <br /> C(-far( / LI/he Ali-m(6- "c rr 1.O d's& 6�� QMO1D L) _ <br /> '7 ■ AI"Kc "' tz9S- <br /> Amth to cmnpptae?tans roe timapatan and suhndt to rho County ont5 on paver not lass than 8 112111 inches in Size <br /> SBD-6393(R.l i/I I) <br />