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Commerce.Wi.gov County <br /> Safety and Buildings Division Dane <br /> 'SCO 11 S'n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2014-00313 <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(1)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ACKER REALTY LLC 0708-301-6634-0 <br /> Property Owner's Mailing Address Property Location <br /> 101 E MAIN ST STE 2 <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE / NE '/ Section 30 <br /> WAUNAKEE, WI 53597-1196 (circle one) <br /> T 07 N; R 08 E <br /> H.Type of Building(check all that apply) Lot# <br /> El I or 2 Family Dwelling-Number of Bedrooms 4 4 Subdivision Name <br /> Block# CHERRY WOOD FOREST <br /> ❑ Public/Commercial-Describe Use <br /> City/Village/Town of <br /> 1:1 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. El New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑ Permit Transfer to List previous Permit Number and Date Issued <br /> Before Expiration New Owner - <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At Grade E21 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 /> 750 .4 1874 1880 106.9/108 <br /> VI.Tank Info Capacity in Total #of Manufacturer m <br /> Gallons Gallons Units d o y <br /> New Tanks Existing Tanks m y u N °- <br /> C y 2 2, ca N <br /> d O (n V) rn it O d <br /> Septic or Holding Tank 1650 1650 1 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 220165 (608)831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K, Waunakee, WI 53597-9449 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved ❑Disapproved <br /> ❑owner given reason for denial $1,246.00 10/03/2014 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 />