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_ County Q /� <br /> Safety and Buildings Division I Dane ^- P! <br /> rr _ 201 W.Washington Ave.,P.O. Box 7162 Sanitary Permit Number(to be 611ed in by Co.) <br /> ,>'ra <br /> . Madison,WI 53707-7162 <br /> Si .' State Transaction Number <br /> �a��?ta�y ��r_7i� Application ��6- 0036 <br /> In accordance with SPS 33321(2),Wis.Adm.Cede,submission of this form to the appropriate governmental unit l3 - <br /> Iis required prior to obtaining a sanitary permit. Note:Application forms for state-owned POINTS 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 /> names=in accordance with the Privacy Law,s. 5.'a;(:)(n .Stets_ I—E-R kl iDR∎V E <br /> I. Application Information-Please Prin.:All=zformarion <br /> Property Owner's Name <br /> /� Parcel s <br /> Uud0.50R QUA Kg-1 (GIG I:l(JNGLz - xCA ATin_161 09 It- tS4- LQ1i6 - a <br /> Property Owner's Mailing Address ` Property Location <br /> G.7�1 cm r�IC (' Govt Lot <br /> City,State Zip Code 1 Phone Number r t <br /> �.UCu-t v .%le--e--4- f.J i , 5 3 S `9 S C /+, $t /., Section <br /> D.Type of Building(check all that apply; Lot r T 9 N; R I I E <br /> Ell or2 Family Dwel ling-Number of Bedrooms 1 /g Subdivision Name <br /> gbm.K1SG4ts RtpCrtE <br /> QPublic/Commcrcial-Describe Use RECEIVED <br /> 0 City of <br /> OState Owned-Describe Use NOV B 0 2 SM Number 0 Village of <br /> LP Et Town of 1 2 I S T O L_ <br /> PtPubtchealitt_111)C <br /> III.Type of Permit: (Check only one bot on 11E qt ' licabi) <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> A. <br /> l <br /> 3- ❑Permit Renewal ❑PennitRevisict Q Change of Plumber OPermit TransfertaNety OwnerBefore Expiration Owner List Previous Permit Number and Date Issued <br /> IV.Type of POWTS System/Component/Device: (Check all that atol r) <br /> Non-Pressurized In-Ground !Pressurized In-Ground at-Grade 0 Mound>24 in.ofsuitable soil 0 Mound<24 in_ofsuiiablesoil <br /> Holding Tank ather Dispersal Compon::nt(e plain) E L. FIOO✓ Calf DPretreatment Device(explain) <br /> V.Dispersal Treatment Area Informatom: <br /> Desip Flow(gpd) Design Soil Application Rare(godsf) [Dispersal Area Required(sf) 1 Dispersal Area Proposed(sf) System Elevation J <br /> (p O° - /SOS 1 ts-0 c. C .� 91.'1 g9..5-Ci9. 4 q S <br /> VI.Tank Info Capacity in Total r of 1 Mfanufacturer u =T I <br /> Gallons Gallons Units I 1 - :, <br /> New Tanks I E.dstine Tanta - E _ _ <br /> 1 Fr:TA f i <br /> Septic oe{lelding Tank I ?-E(0 "- ■ I XX, 4 M 0G_ 1 I I 1 <br /> Dosing Chamber CA50 I I USC) t t M EA47 E I x 1 I <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWrTS shown on the attached plans. <br /> Number's Name(Print) Plumber's Sienature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz _-?---- 4A) •-)..,----/- 220165 608-831-8103 <br /> Number's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VM..Countv/De,artment Use Only el <br /> Approved ❑Disapproved Permit Fee Date Issued Issuin pent t, <br /> ❑Owner Given Reason for Denial S 43 1 + f l-3-10(6 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ?attach to couplet=?lam far ttte system and submit to the Ceuets outs on paper not less than S ill sit inches in size <br /> SBD-6393(R. 11/11) <br />