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County k 14 <br /> Safety and Buildings Division Dane <br /> _". J - 201 W.Washington Ave..P.O.805 7162 Sanitary Permit Number(to be Riled in by Co.) <br /> P Madison.WI 53707-7162 <br /> S <br /> f _ .1o/6 — 00376 <br /> State Transaction Number 1 <br /> ` Sanitary F.er:�it Application <br /> `In accordance with SPS 33321(2),Wis.Adm.Cede,submission of this form to the appropriate governmental unit <br /> 1 is required prior to obtaining a sanitary permit.Nur Application fors for state-owned POWTS are arbmitted to Project Address(if different than mailing address) <br /> the Department of Safety mid Professional Service.Personal information you provide may be used for secondary '/ <br /> awns in accordance with the Privacy Law s.1.51141)(m),Stau'. t{A-(4 X55 A tiJ A'( <br /> I.Application Information-Please Prier_All Zaformation <br /> Property Owner's Name 'Parcel d <br /> DON. AI.LD TOA4(JE 1nF4z4EY CIO M -IF 4 B1441.0144 alp DES14tI) o911- 303-042.0-O <br /> Property Owner's Mailing Address Property Location <br /> YO g0 Y 104 Govt Lot <br /> City,State Zip Code ' Phone Numbs <br /> SUh1171ZI�ICCIr WI NE %. SW Y,SoctionjQ <br /> 53590 T 9 ,N; R II e <br /> II.Type of Building(cheek all that apply; Lot S <br /> ®l or2 Family Dwelling-Number ofBedroom., �j 4o Subdivision Name <br /> Block3 5R1.5-rOL err OtrZ.0EIJ5 <br /> QAsblic/Commercial-Describe Use <br /> 0 City of <br /> QState Owned-DmcnbeUse • a.ECE t } weber f❑pVillageof <br /> 1 Vi groom R ff.LSi))L- <br /> 111.Type of Permit•. (Check only one bon on line aciatpfitiNlie Rif applicable) <br /> A <br /> arNe r <br /> w System ❑Replacement System rs• olding Tank Replacement Only ❑Other Moegfiration to Existing System(erpiain) <br /> tnVironmenta,Hentrh Damn 8. ❑Permit Renewal ❑Pettit Revisic t ❑Change of/neater ®Pamir Transfer to New Lis P1ev1ous Permit Number and Date issued <br /> Before Expiration Owner <br /> 1 1V.Type of POWTS System/ComnonentiDevicc (Cheek l'ai that anol'v) <br /> QNon-Prewurvedrrhi-Ground QPressuriuc Ire-Ground D e-G oe QMound>-24 in.of suitable soil ' Maard<24 i.of suitable soil <br /> ❑Holding Tank DOUter Disperse/Component(explain) OPtereannant Device(explain) <br /> V.Dbpersal/freatmostt Area Information: <br /> Design Flow(gpd) Design Sol Application Rate(w"odst) li Dispersal Amu Reyyiad(sf) Dispasal Area Prop (sf) System Elevation <br /> . C /2-6 o 1 !yyy I Se-r' /krstT <br /> VL Tank Info Capacity in Total d of Manufacture $ 4 <br /> Gallons Gallons Units a _ <br /> Raw Teaks I Edna"Tadu o g AI C 3 1 <br /> r=U v:7. ai i=C <br /> Sack crallelding Tork it,5o IOC) a- meAve iG <br /> Baalmatemaer boo J 1 51)&0 a I kte Pro_ L <br /> 'VII.Responsibility Statement-I,the awdcraigacd,ammo respoesibity for installation of the POWTS shows on the attached plans <br /> Plumbers Name(Print) Plumber's Signature MP/MPRS Number Busiaas Phone Number <br /> Andrew W 1lrieinholz —A.,) 220165 608-831-8103 <br /> Plumbers Address(Sneer,Ow.Siam Zip Code.) <br /> 8813 County Highway K,Waunakee WI 53597 <br /> vim County/Deparlment Use Only <br /> �Apptoved ❑Disapproved Permit Fleee Dale Issued issuing ignmre <br /> ❑owmeciren Reasons tbrllnenial s ('V`�' 1 +2060 <br /> IX.Conditions of Approval/Reasons fbr Disapproval !(_ ��./ rNLC.3^<J � , <br /> 3 t f F c.fA ?A/ j)EJ?6"6 --� ��' '� — b <br /> —it. f&T' "'KO ry- 7 ,IP, r(7 APO is F6�f Da✓rr.a.voc <br /> Few- roe Canso -1<a4// ,f.qL eiCe t4# (. 'Fro J Ca rA t <br /> Asset♦ra a sptets pram tar(ea taum awl whe,Y a Cm aq eats as WOec ten than'ut a l lochs s sin <br /> C(6• P (f C6R42(C-- <br /> SBD-6398(R.11/11) <br />