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_ - --- -_ ..._., Count/ jJ <br /> J Safety and Building;Division Done ice, <br /> =' I 201 W.Washington Ave.,P.O.3o;7132 <br /> J 9 Sanitary Permit Plumber(to be Filled h by Co.) <br /> Madison,WI 53707-7182 <br /> 1 3- )oi47— 0c3-- <br /> San tdl °l i iit1 Application State Transaction Number <br /> In accordance with SPS 32331(2),Wis.Adm.C..-de submission arhis form to the appropriate governmental unit <br /> is required prior to obtaining a sanitar•permit. ;rate Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Depataeent of Saiecy and Professional Service. Pe tonal information you provide may be used for secondary <br /> pures.%:r.accordance v.ith'Ste ri•;aci Lao:,s.'.S.44i)(n).Stats. KALrE y,,,l 6GiLL.-7 PASS <br /> I. .Application Information-Please Prin.:All Information <br /> Property Owner's Name <br /> A 1 Parcel n- <br /> Iti•-kNU5C./2 G;uA•KrL.Y 1-LC (C/O t�I.WlA•tsi C'C 1-7.0+ttrcS l^AC.1 o911- iQ}Q - (522_—o <br /> ?ropem;Owner's Mailing Address Property Location <br /> 5535 C-lizASSLAt.LDzALE Govt.Lot <br /> City,State Zip Code Phone Number i t. <br /> N E /�, s 1~ /,Section 15 <br /> MNIzst-i- t tjJ1 53559 <br /> 13.Type of Building(cheek all that apply; ��{{ Loth T 9 N; R 11 E <br /> R1 or2 Family Dwelling-Number ofBedrooms "1 I1 Subdivision Name <br /> Block: PjLAKI•lSC,?S'S Ri0(ne.-- <br /> ❑PublidCommcrci l-Describe Use R <br /> City of <br /> QState Owned-Describe Use ViVE Li Village of <br /> t)EC Q 8l Z076 El Town of F3 FC t•S i o L <br /> M.Type of Permit: [Coed:only one be: on li xe;i.P62041p}g-I,�i>z.3 if applicable) <br /> A' i New System ID Replacement 3.-stem I I 1Traat t il Replacement Only ❑Other Modification to Existing System(=plain) <br /> B. 0 Permit Renewal PermitR visic1 II0ChangeorPlumber QPerm New LtscPreviousP�tnit Number and Date Issued <br /> 'J <br /> Before Expiration t I Owner 1 <br /> IV.Tyne of?ONTS 3ystcmi Camaoueot Device: (Check all that 5001Y) I <br /> ®Non-Pressurized In-Ground 0Pressurized to-C:wnd Dt Grade DMvtound>24 in.of suitable soil Li Mound<24 in-or suitable soil <br /> 0 Fielding Tank QOther Dispersal Compon_at(c:plain) DPrarea rent Device(explain) <br /> V.DispersallTreatmcnt Area Information: l <br /> Design Row(gpd) Design Soil Application ate(gpdsf) Dispersal Area Requited(sf) r Dispersal AretProposed(sf) 'System Elevation <br /> (.e00 C*' `Sti 3 <br /> CI I f1ia 1A, ', 91.2 r, 9`ts,0r <br /> VI.Tank Info Capacity in Total h of 1 Manufacture 3 c' 1 <br /> Gallons Gallons Units . p ' ' I ` il <br /> New Tanis Edadng Tanis u $ ^e et <br /> C r✓U CT;h r I n. — <br /> septic nFFldeiing Tank i i-8,(,a 1-- i I afi6O 1 I MEAD-E. iI ' 1 1 l <br /> eating Chamber I (550 I I (05d I I Me.A 4)-a I I <br /> VII.Responsibility Statement-t,the undersigned,assume responsibility for installation of the POWTS shown oo the attached plans. . <br /> Plumber's Name(Prior) Plumber's Signature MP/tvIPRS Number Business Phone Number <br /> Andrew W Nteinholz .1 L...� 220165 608331 8103 <br /> Plumber's Address(Street,City,State,Zip Cede) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing entt S [cure <br /> ❑Owner Given Reason for Denial S '-- r2-$"29( ��� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> I <br /> .'.naafi to eomptets?iota rest%%esateno and submit to the County outs as paper not @se than 0 U1 x.11 inches in size <br /> 350-6393(R.WI <br /> • <br />