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6 08-831-81 07 MEINHOLZ EXCAL'ATING 812 P 02 MAY 02 '@8 1 @:22 <br /> V IL Ih ll V1 t-; 1 1 <br /> • <br /> APR 2 2 20Q8 1 C'lie&k Y 4/0073 06ro ,2445 <br /> t''' Gnt7iP>ReTt •w Safety anc dings Division County <br /> 201 W.Washithlton A,c.,P.O.Box 7162 yr.j� <br /> os CCU n S 1!1 Pct tic I eaIth fin+WI X)707--7162 Sanitary Permit Number(to be filial in by t o) <br /> pirement of Consomme Envy onftlental Hoatt#* 517 n <br /> Sanitary Permit Application StateTransect` Number, <br /> In acdordance with a.Comm.13.21(2),Wis.Mm.Code,submission of this form to the appropriate governmental 1 F`C ro(+V6 '14.7771 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-vaned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.IS.04(lXi's),Stars. I `� <br /> I. Application Information—Please Print All Information M GtJc�e.1 /Q'4[S %r • s' <br /> Property Owner's Namc <br /> ,�"!a/k /I»r-. a...-J /z-k-r" Parcel <br /> o:3-.r..0i-o <br /> Property lkvner a Mailing Address Properly Location <br /> e5-38 Sfv,t d br- . Ci-rcJc_ <br /> City,Slate I L <br /> Zip Code Phone Number tjOY�Cl t.t1 ot,A ,5 as yry Section .2—' <br /> M:dot iIQ-'(vet ' 4.)t . SAS.4. Z T 6 N, R (circle one) . <br /> B.Type of Building(check all that apply) Lot N C or W <br /> I or 2 Family Dwelling_Number of Bedroons 9 / Subdivision Name <br /> Block N /47;Age c s>tr, C, <br /> ❑Public/Commercial cial—Describe Use ✓ <br /> 0 <br /> • <br /> City of . <br /> D State Owned—Desrn'bc Use CSM Number ❑Village of <br /> Town of ....1>: j ot44aG, <br /> III.Type of Penult: (Check only one box on line A. Complete use II if applicable) . <br /> A' New System ❑Replacement System ystcm ❑Trcatraeat/ihoWing Tank Replacement Only Cl Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision 0 Change of Plumber ❑Permit Transfer to New" Lkt Previous Permit Number and Deb Issued _..__ <br /> Before Expiration Owner <br /> IV. a c of POWTS S atens/Component/Devic= (Cheek all that apply) <br /> ❑Non-Pressurized In-Crowd 0 Pressurised In-Ground ❑At-Grade Mound<24 in of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ©Pretreatment Device(explain) <br /> V.DispersaVFreatmeat Area Information: <br /> Design Plow(gpd) Design Soil Application Ratc(gpdsl) Dispersal Area Required(at) Dispersal Area Proposed(al) System Elevation <br /> 4a 00 /. 0 bop 40 oA .se."- of :S; fe <br /> VI.Tank Info Capacity in Total N of Manufacturer - <br /> Gallons Gallons Units -► g <br /> New Tanks Existing Tanks 8 <br /> 1 uS.0 so wQ <br /> Septic..-MpldingTaak /2 8 td r 1284 ,J`"/ja p14.. X <br /> Dosing chamber 6.!'0 `S ` <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation Of the POWTS shown on fits attached plans. <br /> Plumber's Name(Print) Plumber's Signature itl!•/MPRS Number Business Phone Number <br /> A'' -;.., L.) -/I42;•-..L J2. , ¢L"2 4..) . ---+ is/6s' 6 dg s-3)-8ic,3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6S;3 0.TH "r.--" c:.,. <br /> w�.:* ! w.- _ sass ? <br /> V[[I.County/Department Use Only <br /> %ppreved 0 Disapproved <br /> Permit Fee_ Date Issued 7ssn' Ag Si <br /> ❑OwrrcrGiven Reuon for Denial <br /> s r5 4(-2y.--08 c yot,,_____._ <br /> IX.Conditions of Approval/Reasons for Disapproval - <br /> 1NL;THIS AP*'fi0VAL,DANE COUNTY <br /> ENVIRONMENTAL HEALTH DOES NOT HOLD ITSELF <br /> LIABLE FOR ANY DEFECTS IN PLANS OR SPEC FICA- <br /> Mod to complete plaits(or the system and se basil is the County only on paper lot i +i ANY <br /> a i <br /> �I�It.� ' '�' IN OR N DAMAtzE.THAT MAN <br /> RESULT IN OR AFTER INSTALLATION AND RESERVE: <br /> SBD-6348 R.01/07)Valid thtu 01!09 TEE RIGHT TO ORDER CHANGES OR ADDITIONS <br /> SHOULD CONDITIONS ARISE MAKING THIS <br /> NECESSARY. <br /> • <br />