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County I�{- - <br /> Safety and Buildings Division <br /> 1 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be fined in by Co.) <br /> .ASP 13't Madison,WI 53707-7162 <br /> =r S i 3 a 0 r Doo53 <br /> '!1:•.:o::.,- - State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS 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 /> purposes in accordance with the Privacy Law,s_15.04(1)(m),Stats. L„J G V1 n.CzcS %%/c - <br /> I. Application Information-Please Print All Information Parcel <br /> Property Owner's Name <br /> 67/0- 35A-0-7 37-v <br /> rd r~. If cI e.SS, cc-, S — Property Location <br /> Property Owner's Mailing Address <br /> C t, �. ca I�, Govt Lot <br /> SG 0 0 oC--ex;�5 4zTrr J! P ,S— <br /> City,State Zip Code Phone Number N 6 1/4, AU t✓ '/4, Section <br /> ,ic, tc._.e / co; . ' 5355 T 7 N; R. /D E <br /> 11.Type of Building(check all that apply) Lot# <br /> L /b'� Subdivision Name t <br /> ®I or 2 Family Dwelling-Number of Bedrooms 17 / /41)!1 i Mil/ i'--Block# / <br /> ❑public/Couunercial—Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ['State Owned-Describe Use RTown of tom'^"f'5 G1-40< <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. cw System ❑Replacement System ❑Treatrnent/Hotding Tank Replacement Only []Other Modification to Existing System(explain) <br /> List Previous Permit Number and Dale Issued <br /> B. ❑Permit Renewal ❑Permit Revision <br /> Change of Plumber OPetmit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check 1'"all that apply) <br /> on-Pressurized In-Ground Llrressurized In-Ground At-trade ['Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> '/E, " <br /> oHolding Tank (goiter Dispersal Component(explain) 2----FI9 Gn/ []Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Z. <br /> Dispersal Area Proposed(sf) System Elevation <br /> Desi Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) rspersal 6//‘'S � <br /> b y c1 / s"ao l,Si`.b 4 / ,X17/ q�f r Y <br /> VL Tank Info / Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> iii <br /> New Tanks Existing Tanks d o d 2E a <br /> 0 <br /> a u in ix ti iE O w <br /> Septic er4lelding Tank /2. V v .--. /2 ov / ..,11.e...0.--0-_ <br /> Dosing Chamber 8 UV —, god - / V <br /> VD.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 MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz - C. 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing .:ept S•.,..,• • <br /> pproved ❑Disapproved $ 3-5-2Ai 7 , 4,11 vY ❑Owner Given Reason for Denial L�" <br /> ) 1'j4:5- <br /> IX.Conditions of Approval/Reasons for Disapproval _ <br /> r�z w GE -S 6'. s A, = lst' sQt Ff, E V <br /> MAR 0 8 2Q17 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 lei a II bier in <br /> bli s zerG th MDC <br /> Environmental Health <br /> SBD-6398(R. 11/11) <br />