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_ County <br /> Safety and Buildings Division DAh4E JXA-- <br /> - D S • 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be tilled in b7;Co r <br /> P Madison,WI 53707-7162 <br /> _--- - 3—ao/6- op-3-76 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 303.21(21.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 I if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> .0 wses in accordance with the Privacy Law,s.15.0411 X ml,Stats. <br /> I. A..lication Information-Please Print All Information L-1Y'COtvv Rd, <br /> Property Owner's Name Parcel# <br /> 1 Sieve GCinSes,- ose7q-42-854(C)-0 <br /> IProperty Owner's Mailing Address Property Location <br /> 6225 Nili d, Govt.Lot <br /> City,State Zip Code Phone Number <br /> N W /,, NW /,, Section 1`{- <br /> Q(-'on WI X535-75 T 5 N; R q E <br /> 11.s'ype of Building(check all that appl " Lot C <br /> I or 2 Family Dwelling-Number of Bedro I Subdivision Name <br /> Block# <br /> ❑PublicrCommercial-Describe Use — <br /> ❑City of <br /> ['State Owned-Describe Use CSM Number ❑yVillage of <br /> ' 14-50-7 J Town of 0feLf Cfl <br /> lii.Type of Permit: (Check only one box on line A. Complete line B if applicable) v <br /> II MI New System El Replacement System ❑Treatment'Hulding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> :71 List Previous Permit Number and Date Issued <br /> ❑Permit Renewal ❑Permit Revision 1 hange of Plumber Orermit Transfer to New <br /> Before Expiration 'Owner <br /> IV.Tyre of POINTS System/Com.onent/Device: Check all that1a..Iv) / <br /> Jon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade `❑�Inwdz-24 oJ f <br /> suitable soil ❑Mound<21 in,of suitable soil <br /> ❑Holding Tank ❑Otter Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis.ersal/Treatment Area Information: <br /> Design Flow(god) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> (oc0 ' , 4 - ia5oD . 1,512 'ch".2'g5.7'452' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 7t -` a aa New Tanks Existing Tanks n7. = y r - E 0 li s_ Li <br /> a U rn ;, N ir.V a. <br /> Septic or-H1a4AiorTank r%rr/tie --- 1250 I N EASE. <br /> s Dosing Chamber J755O'" 8400 — 75C' I v. ✓ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) liMil / MP'MPRS Number Business Phone Number <br /> Andrew W Meinholz 220165 608-831-8103 <br /> Plumber's Address(Street.City.State.Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/De.artment Use Only <br /> Approved ❑Disapproved Permit Date Issued Issuing Agent Signature <br /> S <br /> ❑Owner Given Reason for Denial -r -,+r - . t , <br /> IX.Conditions of Approval/Reasons for Disapproval ( I 1 <br /> SCANNED RECEIVED <br /> } I <br /> Attach to complete plans for the system and submit to the County only on paper not less than g V2 x I I inches in size <br /> • Public Health MDC <br /> Environmental Health <br /> SBD•63)0(R. I 1 I I) <br />