Laserfiche WebLink
commerce.W1.gov County <br /> Safety and Buildings Division Dane <br /> tatisconsin 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Gornmerce Madison,WI 53707-7162 13-2014-00382 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate <br /> governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-owned <br /> POWTS are submitted to the Department of Commerce.Personal information you provide may be used for Project Address(if different than mailing) <br /> secondary purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name <br /> Parcel# <br /> MREC VH MADISON LLC 0708-203-6111-0 <br /> Property Owner's Mailing Address <br /> Property Location <br /> 6801 SOUTH TOWNE DR <br /> City,State Govt.Lot <br /> Zip Code Phone Number SE V S SW y, Section <br /> MADISON, WI 20 <br /> 53713 (circle one) <br /> II.Type of Building(check all that a PP l Y) Lot# T 07 N; R 08 E <br /> El 1 or 2 Family Dwelling-Number of Bedrooms 11 Subdivision Name <br /> Block# SPRUCE HOLLOW <br /> ❑ Public/Commercial-Describe Use <br /> Wr <br /> CityNillage/Town of <br /> El State Owned-Describe Use CSM Number <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. 0 New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal Permit Revision List previous Permit Number and Date Issued <br /> ❑ ❑ Change of Plumber ❑ Permit Transfer to <br /> Before Expiration New Owner <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in of suitable soil <br /> ❑ Holding Tank ['Other Dispersal Component: <br /> ❑Pretreatment device: <br /> V.DispersaVCreatmentArea Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 750 .4 1875 1890 see plans <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units m o m <br /> u U <br /> ,o g New Tanks Existing Tanks u m <br /> a O i7 8 d s O a <br /> Septic or Holding Tank 1650 1650 1 <br /> meade ../ <br /> Dosing Chamber <br /> 800 800 1 meade ✓ <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 Meinholz Permit application completed online <br /> 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 /> ET Approved ❑Disapproved Permit Fee Date Issued <br /> Issuing Agent Signature <br /> Downer given reason for denial $431.00 11/04/2014 I Issuin Michael Griffin <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br />