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County. <br /> r Safety and Buildings Division tu. <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> SCANNED <br /> Madison,WI 53707-7162 <br /> / 3 -Jot7- bo oSl <br /> ali'i ermit Application State Transaction Number <br /> ,ante with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> ,aired prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> ,e 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(I)(m),Stats. S I-0 C./ (rG// D✓ art. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> /2;6-1, •Gt. /'Cosct,ta, 6rt,,_SS vQ/L -3W- 9370— o <br /> Property Owner's Mailing Address Property Location <br /> hi BS,S FCeYtft-rG.. 20 a_e2- Govt.Lot <br /> City,State Zip Code Phone Number .5L r/, _s-e- v,, Section 3 Y <br /> ✓'r i-1SAa/l (A); 3 6-5-5 T e3 N, R /a. E <br /> II.Type of Building(check all that apply) Lot# <br /> 0 or2 Family Dwelling-Number of Bedrooms Subdivision Name {{ <br /> V Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use <br /> /`.// 7,5 [ 1'own of / I< <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A_ <br /> New System ❑Replacement System ['Treatment/Holding Tank Replacement Only []Other Modification to Existing System(explain) <br /> List Previous Permit Number and Dale Issued <br /> B. ['Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New 1 <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Ion-Pressurized In-Ground ❑Pressurized In-Ground DAt-Grade ❑Mound>24 in.of suitable soil ['Mound<24 in.of suitable soil <br /> / ec <br /> ❑Holding Tank Either Dispersal Component(explain) Pretreatment Device(explain) <br /> V.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation r <br /> y, o . `/ / 2-s' //3(71 98.x- 98. t 9 , d <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units . u <br /> New Tanks Existing Tanks o _I 2 0° .8 m 2 <br /> du m m vi wO P. <br /> Septic or.14oldieg Tank / C Sa —. /CAS e 2 .4.ta°-- 1/47{ , <br /> Dosing Chamber 4 o d — Coo / ./..- _ i <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. 1 <br /> Plumber'sName(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Meinholz 4 (,. 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Depatiment Use Only <br /> Permit Fee Date Issued R issuing riially proved ❑Disapproved $ e(e ( D -ss _�r ( � c <br /> ❑Owner Given Reason for Denial ] r <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RECEIVED <br /> MAR 0 7 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less tban 8 in xt II Inchu31icq'`Health MDC <br /> Environmental Health <br /> SBD-6398(R.11/11) <br />