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commerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> isca n s i n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of commerce Madison,WI 53707-7162 13-2014-00347 <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 Project Address(if different than mailing) <br /> POWTS are submitted to the Department of Commerce.Personal information you provide may be used for <br /> secondary purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> DANIEL K BOEHNEN 0907-134-9175-0 <br /> Property Owner's Mailing Address Property Location <br /> 101 WND ST <br /> Govt.Lot <br /> City,State Zip Code Phone Number SW y, SE y., Section 13 <br /> NEW GLARUS, WI 53574 (circle one) <br /> T 09 N; R 07 E <br /> II.Type of Building(check all that apply) Lot# <br /> El 1 or 2 Family Dwelling-Number of Bedrooms 4 2 Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use <br /> City/Village/Town of <br /> ❑ State Owned-Describe Use CSM Number Town of Roxbury <br /> 10506 <br /> 111.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. Q New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> List previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑ Permit Transfer to <br /> Before Expiration New Owner - <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> El 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: ❑Pretreatment device: <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 .4 1500 1500 89,87.5,86 <br /> VI.Tank Info Capacity in Total #of Manufacturer a <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks 42 2 m 2 TD arm <br /> a U C/) in a 0 a <br /> Septic or Holding Tank 1286 1286 1 Meade ✓ <br /> Dosing Chamber 650 650 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) Plumbers Signature MP/MPRS Number Business Phone Number <br /> Andrew Meinholz Permit application completed online 220165 (608)831-8103 <br /> Plumbers Address(Street,City,State,Zip Code) <br /> 6813 County Highway K, Waunakee, WI 53597- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> ❑ Approved ODisapproved <br /> (Downer given reason for denial $431.00 10/27/2014 Perry Dahl <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Additional borings needed. Proposed cells too far outside of borings. <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 />