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^`;rasa:N`(:l. i f <br /> — <br /> Coun t}' <br /> `-' '`.• <br /> "'' ` I S�afety and Buildings Division <br /> Oa-,ZE, <br /> ¢p;�Vit4 i� <br /> ;s .•$ �r ��. <br /> APR <br /> 201 Nv.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ;`•, f v: ' .l ' 2� Madison,WI 53707-7162 <br /> s!.4,;--_,;:k.,....� �,t h ,;th / 3- 2oz/ 0 cot / <br /> yrt. a- Environrn <br /> anri1<arrcy t er1. <br /> ppiication Stare Transaction Number <br /> In accordance with SPS 333 21(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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. t5.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information 5-4 Me <br /> Property Owner's Name Parcel# <br /> Kofr_t. ICc�{r ( 0 - 37-37- 25-61 - 7 <br /> Property Ownepts Mailing Address Property Location <br /> 1 0016 u 5 ! u-y I ' Govt.Lot <br /> City,State / Zip Code Phone Number t <br /> 13 22 J Sl v,, 51,,Cei 'A, Section 3 <br /> [Ltck C.,41t (A., -_ ,S 3,51 s (circle one) <br /> U.Type of Building(check all that apply) Lot# T N; R C E or w <br /> ❑ I or 2 Family Dwelling—Number of Bedrooms 1 Subdivision Name <br /> Block# <br /> 0 Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> 7r 7 ❑Town of 01 G c k j'cs l <br /> I <br /> tIi.Type of Permit: (Check only one box on tine A. Complete line 13 if applicable) <br /> A. <br /> 0 New System 0 Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to ExistingisSystem(explain) i <br /> gECo;utirGr VI1(4.1 i <br /> B• 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued 1 <br /> Before Expiration oI <br /> Owner SAN-44144 <br /> IV.T ,e of POWTS S stem/Comsonent/Device: Check all that a•il <br /> r <br /> Non-Pressurized In-Ground 0 Pressurized In-Ground ® At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> I <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) l Dispersal Area Proposed(st) System Elevation i <br /> I I <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° <br /> New Tanks Existing Tanks U <br /> 1E - d 1 1 # <br /> a- U r7 r cel o-° 0- <br /> Septic or Holding Tank /2-5-v /2 SO I �^e S� <br /> Dosing Chamber 5-0 <br /> 75-0 <br /> 5 0 ( '` 1 I <br /> Lte?G 6C <br /> VII. Responsibility Statement- I.the undersigned,assume responsibility for installation of the PO'VTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number <br /> KENNETH MEIER 224144 608-849-8771 <br /> 6e-t .../2.-ci <br /> Plumber's Address(Street,City,State,Zip Code) jc .-yy/ e; .= <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only _ <br /> ® Approved ❑ Disapproved Permit Fee Date Issued I Issuing •j►.ignature <br /> (1:1 Owner Given Reason for Deniali _ ,zzA,,a/ AlVote"Wire._ <br /> s 282.00 4/30/2021 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Existing tanks to be pumped and/or inspected prior to final inspection. <br /> Attach to complete plans for the system and submit to the County only an paper not less than A ins I I inches in site <br /> SBD-6393(R. I I/1 I) <br />