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` ,.. �r Safety and Buildings Division I t ounty'tc.% ., <br /> .. <br /> D -.- <br /> - 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S 1-: Madison,WI 53707-7162 <br /> ,�' 3 C)01 '3— -�r}s r v% <br /> If <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38311(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 stare-owned POWTS 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.15.04(1)(tn),Stats. <br /> I. Application Information—Please Print All Information OW I {5 <br /> Property Owner's Name Parcel# <br /> i :leis IA;,A4 ir:sv&: r-rl•-\ / 049 CD-2-'t i-"3 ....-, -2 <br /> Property Owner's Mailing Address Property Location <br /> -7C-71 CAel *vy 113 i24. -/ Govt.Lot <br /> City,State Zip Code Phone Number OE y NE 'A, Section 2+ <br /> nialv t 1>\s i — 53'5241 (•5- s3 T °I N; R a E <br /> II.Type of Building(check all that apply) Lot# <br /> Dior 2 Family Dwelling-Number of Bedrooms _4 -+ "" Subdivision Name <br /> Block i <br /> ❑Public/Commercial-Describe Use 0 City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> El Town of 1>-i re-- <br /> liI.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A 12fNew System ❑Replacement System 0Treatment/Ho1ding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ['Change of Plumber 0Permit Transfer to New List Previous Permit Number and Daft Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ['Pressurized In-Ground QAt-Grade ['Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank Either Dispersal Component(explain) an-treatment 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 /> tee0 ✓ , 4 r F. cx 15,2 <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units s, 0 o 0 o <br /> New Tanks Existing Tanks u o u ` 0 0 m is <br /> P.U rn H co W u a. <br /> Septic or ihrktiug Tank 1266, 1206 l P(EACE X <br /> Dosing Chamber <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 .--A1.,{f t,J. -1 220165 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 <br /> VIII.County/Department Use Only <br /> proved ❑Disapproved Permit Fee Date Issuedd Issuing , r-,.•. <br /> $ <br /> ❑Owner Given Reason for Denial 67 1 c7 I y■ /% _`_ <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> RECEIVED <br /> JUL 11 1011 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 11 inches in size <br /> ,+tea '4. '",r z; ) Public Health*1DC <br /> y '-' . Environmental Health <br /> SBD-6398(R. 11/11) <br />