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County <br /> Safety and Buildings Division Dane J vtv <br /> I D 201 W Washington Ave., P.O. Box 7162 Sanitary Permit Nutnherlto he tilled in by Co) <br /> S SCANNED Madison,WI 53707-7162 <br /> ----....,... 17• a of 1 . doo 4.fib <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 333 2I(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 POIVfS 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. I S 04(1)(m),Stats. S Ut t■1 S el- DR I V . <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel If <br /> ALA1J ti' Kl21S !-tAWE.RSa J / 0(008- 753 - Olio - o, <br /> Property Owner's Mailing Address Property Location <br /> 1.bo1. RED TAIL Govt.Lot <br /> City,State Zip Code----. Phone Number <br /> VEr2i0NA Vi N '/,. SYJ th, Section 5S <br /> IT.Type of Building(check all that apply)/,, Lot 4 T N' R 8 E <br /> ©I or 2 Family Dwelling-Number of Bedrooms 4 3 i Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of , I <br /> 14o3 1/0 �- t/RTown of -ao-N A <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ©New System ❑Replacement System <br /> ['Treatment/HoldingTank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ['Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of PORTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ['Pressurized In-Ground ['At-Grade Mound>24 in.of suitable soil ['Mound<24 in.of suitable soil <br /> ['Holding Tank ['Other Dispersal Component(explain) ['Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Require (st) Dispersal Area P posed(st) System Elevation <br /> (.12 00 i r 6> / !t7 ° ° 6Q0 ,, Mid Z /6 c , SEA-- AT- s 1 re_ <br /> VI.Tank Info Capacity in Total of Manufacturer <br /> Gallons Gallons Units u o u <br /> New Tanks Existing Tanks :° +▪ u `v n n <br /> u 2 u a ? :s <br /> Septic or Holding Tank J • ' <br /> tai 1D8(v ,D- ti-tEAUE <br /> Dosing Chamber (05o r (yY 1 me.AfDe- <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/fv1PRS Number - Business Phone Number <br /> Andrew W Meinholz /1 _ 10 . 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) -��t� <br /> 6813 County Highway K,Waunakee WI 53597 . ---- ----- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued issuing A•e -T re <br /> ❑Approved ❑ Disapproved + <br /> ❑ Owner Given Reason for Denial 1} / 62-42 / /`rte- 'Le <br /> IX.Conditions of Approval/Reasons for Disapproval .�/ <br /> pea 7-4v7— homop 5/re .4fro -#� /s- Fee,- '-�w S<dPE ix) RE e V <br /> (TS fh1'GIl•."- 014/0/7-1.6 011 :f' P/571KGOffeGE, e'orrAtt/Yorvt 6re,n,4•jT!//f/ <br /> of ✓tNiek� T 4PFic. /s emu«-&o. FEB 2 3 2017 <br /> Attach to complete plaits for the system and submit to the County only on paper not less than li I!'_.x I I inches in Oublic Health MDC <br /> Environmental Health <br /> SBD-6.98(R. I I/I l) <br />