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_ County <br /> Safety and Buildings Division I Dane k, t <br /> ▪ 'J _ 201 W.Washington Ave.,P.D. Box 7162 Sanitari Permit i lumber(to be filled in by € <br /> ▪ 3' _ — Madison,WI 53707-7162 <br /> f -zThite — bD38°1 : e <br /> . <br /> Sanitary- i ermit Appl_icatioi? State Transaction Number <br /> In accordance with SPS 33321(2),Wis.Adm.Cede,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit i`:ote:Application forms for state-owned POINTS are submitted to Project Address(if different than mailing address); s <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> ,purposes in accordance with the Pri-Dacy Law,s-1 S-',l t(1)(;n),Stets. , ,I I ��S ��� r <br /> 1 L Application Information-Please Prim All=nformation 1Y 1 <br /> Pro Owner's Name fro <br /> ivRo E. J ikcoB;l (c/0 I-t'AKT ID ENO6l.ly (36k(L-0 E-R-S ) 0,5 08— 3 51-- a-o.D-5 --0 <br /> Property Owner's Mailing Address Property Location <br /> 17 9.23 At R PoR Roi Govt.Lot <br /> City,State k) Zip Code ' Phone Number <br /> IA I D D LET ri m IM ty %', 5'� %, Section <br /> 4,74- T 8 N; R 8 E <br /> II.Type of Building(check all that apply; Lot 4 <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name I I <br /> Block 4 L 1 nv'.� -fLjL- 4T <br /> \f l-L L-.. <br /> QPublic/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use R E C E I\I E M Number 0 Village of <br /> ppe�rr ff r� grown of 5P t21 kits)CI ELI <br /> 1 III.3 Type a Permit: (neck only one bolt on IINCL.`Listg line B.if applicable) . <br /> At.risi lew System ❑Replacement <br /> Syllabi 0 EfrzlitRtEnr/1lold'mgTanl:Replacement Only ❑Other Modification to Existing System(explain) <br /> Environmental Health <br /> B. ❑Permit Renewal ❑Permit Revisic: ❑Change of Plumber OPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration ( Owner <br /> I IV.Type of POWTS SvstemiCamnonentDerce: (Che r that apply) I <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Groun t-Grade 0Mound>24in.of suitable soil 0Mound<24 in_of suitable soil <br /> Holding Tank QOther Dispersal Component(slain) DPretreatznent Device(explain) <br /> V.Dispersal/Treatment Area information: <br /> Design Flow(tgpd) Design Soil Application Rate(godsf) Di ers Required(sf) Dispersal Area Proposed(st) System Elevation <br /> Z/600 • & 2 e,)o o oa Sf✓T AT- L're- <br /> VI.Tank Info Capacity in Total #of Manufacturer a <br /> Gallen Gallons Units 'a <br /> Now Tanks I e acting Tanks 2 _.'j <br /> L U in in N u <br /> Septic or Holding Tank 1 a 8(p ` I I aPr(,o 1. I 1,4 E A-D E I ,•G I <br /> Dosing Chamber (i 5 0 1 (150 I I " - D E X <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature 4lP/Iv[RRS Number Business Phone Number <br /> Andrew W Meinholz ✓ _ W. 220165 608-831-8103 <br /> Plumber's Address(Street,City,Stare.Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use-Only II <br /> proved ❑ Disapproved Permit Fee Date Issued sBsuin gent Si w • 7 <br /> ❑Owner Given Reason for Denial 4 /4-46 l2 / ie,_` - `_ ~ <br /> n <br /> IX.Conditions of Approval/Reasons for Disapproval 40101P- <br /> L <br /> ..ttach to cotnptett?tans Tar ems-`stem and submit la the Canary nail oa paper ant less than a if!x:11 inches in size <br /> SBD-6393(R. 1 I/11) <br />