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.r2t., ,i--•. County <br /> Safety and Buildings Division U l■ g.(4- <br /> .1 s <br /> P l-L. SCAN N D W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI 53707-7162 <br /> b. `P <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Mm.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 Scrvies. Personal information you provide may be used for secondary n •�� L T <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stars. N . 6 <br /> I. Application Information—Please Print All Information Parcel# <br /> Property Owner's Name <br /> D -L/;d. - - KI.INi&R. .- o51/ - 3,-.2— 1076 — gam <br /> Property Owner's Mailing Address Property Location <br /> A oL ta /V . t ra ,5-1-. Govt.Lot <br /> City,State/� f' Zip Cod Phone Number s(,.J t/� /•J(A) V4, Section 3'' <br /> SCA.r� Oa:f;z (Ai: 'S)Block T a) N; R // E <br /> II.Type of Building(check all that app 41. Lot# <br /> / Subdivision Name <br /> ®1 or 2 Family Dwelling—Number of Bed ..ms•ms <br /> (r� # I <br /> OPubliclCommercial—Describe Use O City of <br /> CSM Number 0 Village of <br /> ❑State Owned—Describe Use <br /> 7 6 3 t? 5r Town Town of T3 r S it.I ..-' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System O Replacement System 0 Treatment/Holding Tank Replacement Only OOther Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. O Permit Renewal O Permit Revision OChange of Plumber ElPermit Transfer to New j <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: {Check all that apply) <br /> 1pn-Pressurized In-Ground OPressurized In-Ground DAt-Grade OMound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> OHolding Tank OOther Dispersal Component(explain) OPretreatment Device(explain) <br /> V.Dispersal/TreatmentArea Information: <br /> Design Flow(god) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation i <br /> (.9od / . `f i / S—<)C JS 0 9s2-' 9p-1.i g4l.6 ,- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units m o ,, ., = <br /> New Tanks Existing Tanks ti ii = 2 $ m 2 <br /> w U 65 i rn a.o O, <br /> Septic or Holding Tank /2-0 6 /2$6 2- 1}J.e ,..--,. y <br /> Dosing Chamber 65—° _ (,Y6 _ / .L k <br /> VII.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 ,L...) , 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VII County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved ❑Disapproved $❑Owner Given Reason for Denial `3 I ti �_ ia.= /�v <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> i <br /> F <br /> MAR 1 G 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 z 11 ixligNiii 5l&atth MUL <br /> Environmental Health <br /> • <br /> SBD-6398(R. 11/11) <br />