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•a _ .' County 84k.. ' ' Safety and Buildings Division Dine <br /> 7...` 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.)■ <br /> • P •. ,.S <br /> • Madison,WI 53707-7162 <br /> �. 1." - .1-011- oe..) I( <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 Scrvies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.I5.04(iXm),Stets. <br /> I. Application Information-PleasePrintAllInformation Se ri r v. 1 1csscrti CA-' <br /> Prope -Owner's Name Parcel <br /> "iti‘harri '�trrrr�, <br /> c9008-.3i2-2,r-A3-0 <br /> Property Owner's Mailing Address Property Location <br /> 3V-I4 tfJea-lilertrUmoi Te. Govt. <br /> City,State Zip Code Phone Number y, N►n/ '/., Section 31 <br /> Uerev,a 11".1 i 53 5rt3 T 8 N; R E3 E <br /> U.Type of Building(check all that apply) tot#. <br /> �l or 2 Family Dwelling-Number of Bedrooms © Subdivision Name <br /> Mr Block# b.f'LJt"M <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ['State Owned-Describe Use I�- <br /> Lr!Town of SpriY (Gl4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A <br /> 2/New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ['Change of Plumber DPermit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that a. I I <br /> ❑Non-Pressurized In-Ground ['Pressurized In-Ground ❑AKrrade i ` ound>24 in..00f_suitable soil ['Mound<24 in.of suitable soil <br /> ❑Holding Tanker Dispersal Component(explain) Urretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> tedCr .to t, oe-t 1 L.919 0 <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> v e <br /> Gallons Gallons Units m v u u <br /> New Tanks Existing Tanks c 2 8 2 2 a <br /> n.o n i; rn ii.O a <br /> Septic or-Holding Tank 1286 i2e6 I MADE x' <br /> Dosing Chamber 650 Leg() i rvlEAAE x <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 — W 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII ounty/Department Use Only <br /> Permit Fee Date Issued issuing • : A..., <br /> Approved ❑Disapproved 1 t �❑Owner Given Reason for Denial S Iv b/ o7/�/17 - �� r <br /> IX.Conditions of ApprovalReasons for Disapproval <br /> At°""w 4 v re .f vp .4144 AS— peer 'a.,1--A-1-.-(110#.- <br /> #W <br /> ieIVptTtov' Ne GoMI4eTd1Q/ DiSreakt��E 6V614,4774141/ g)ft" S <br /> V ".-.% Tat-Eerie t s A-‘4_,-...44, JUL ii 5 71117 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 ur s 11 inches in size <br /> Public Health MDC <br /> SCANNED Environmental Health <br /> SBD-6398(R. 11/11) <br />