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_ --E County p <br /> Safer/and Buildings Division Dane Ei - � 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit■iumber(to be filled in by Cu.) <br /> a o 5 Madison,WI 53707-7162 <br /> /3-Joii.— 00336 <br /> , a_n 1[liy emit Application State l Transaction Number <br /> In accordance with SPS 32321(?),'Nis.Adm.Cr de,submission of his Corm to the appropriate governmental unit <br /> is required prior to obtaining a sanitary peanii is ate:Application forms for state-osvned PO`.Y7S ar submitted to Project Address(if different than mailing address) <br /> the Department of Safety,'and Professional Servie.:. Personal intonation you provide may be used for secondary A'- <br /> pureses to accordance with the Pcivacri La•o,s. S.4d('.;(a),Stats. fdQ. vJ 4•'/ RO p0 o <br /> 1.Application Information-Please Prim_All:nfot•mation <br /> Property Owner's Name Parcel <br /> PAL.(LS0ki uf-vti.Gf-ME1Sf LLC (c10 A�l$i#1hICE Its ) 09 I 1 - 194- 4534- a <br /> Property Owner's Mailing Address Property Location <br /> 5e)33 C..-t,12-ASSL-A-r-110 1 ' r _ Govt.Lot <br /> City,State Phone• •er <br /> M h�9H 9l�- ( Sul 1,S % <br /> F_ ,Section 19 <br /> 53559 T 9 N; R t i E <br /> I7.Type of Building( eck all tin' .ply; Lord <br /> El or2FamilyDwelling \umber.fBedrooms 5 i Subdivision Name n <br /> _ LE b-LM4'J1 5 rte'91,LTiOrJ <br /> :Public/Commercial-DmericcIA.. ���3�; -r� <br /> =�i--- City of <br /> :State Owned-Describe Us'. NQV 2 8J.itt Number ❑t 'cage of <br /> cap�w /Town of 12 l S TO L� <br /> ill.Type of Permit: (Cn gy eciconlyoneboxoniliue p ht_ '`=ayppiieabie) <br /> •' I 0,New System I Lf Repiaccment System ❑Treatmznr/Holdmg Tapp Replacement Only ❑Other Modification to Ezdsting System(=plain) <br /> I I <br /> B. I ❑Change of Plumber Transfers New List Previous Permic Number and Date Issued <br /> 0 Permit Renewal Permit Revisica - <br /> Before Expiration I Denier L3 - �.G I£' 0033C. <br /> IV.TYoc of 2O't/TS Svrtte:nICoanoaeatDetrce: !Cheek all that aroI71 I <br /> Elision-Pressurized In-Ground 0PressuriLCIn-Craund Or-Grade 0Mound>24 in.of suitable soil Mound 24 in.afauttable tori <br /> :Holding Tank QOthor Dispersal Component(=plain) :Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information.: <br /> I Design Plow(god) Design Soil Application 2ate(_gpdsf) i Dispersal Area Required(st) I Dispersal Area Proposed(st) System Elevation <br /> 15 0 . C I 49 5.-0 I /y d S— 5E1-/3,r S L t-e }I <br /> VI.Tank Info p in + Total ii of I Manufacturer 5 - ^- - I - <br /> Info Ca ac:ty in <br /> pollens Gallons Units L' I H <br /> 4 = <br /> Neu Teats ' i:�stinu Tams = cc B -'+ _ e- <br /> 1 <br /> Septic or Holding Tank /6, •'dD 1 116i—P a f . `2ce� I I I ` I 1 <br /> I 1 I , / I I <br /> Dosing Chamber UU jpv L� I I <br /> IVII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature I MPtMPRS Number Business Phone Number <br /> Andrew VV Meinholz __- '(.--), 220165 608-831-8103 <br /> Plumber's Address(Street,City Swt&Zip Coda) <br /> 6813 County Highway K,Waunakee,A1 53597 <br /> VIII.County/Department Use Only <br /> ❑Approved ❑Disapproved Perm' a Date Issued Issuing Agent 5 igmattte <br /> ❑Owner Given Reason Ibr Denial <br /> TX.Conditions of Approval/Reasons for Disapproval <br /> hams%to complete ideas:at theovstts.and suhmtt to the County only on paper not less than a to a l r inches io size <br /> SBD-6393(R•I 1/l 1) <br />