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commerce.wigov County <br /> Safety and Buildings Division Dane <br /> SCOf S I fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2014-00424 <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 6288 ONWENTSIA TRL <br /> secondary purposes in accordance with the Privacy Law,s.15.04(lxm),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> JOEL D MANKE 0509-063-2020-9 <br /> Property Owner's Mailing Address Property Location <br /> 6288 ONWENTSIA TRL <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW 1/4 SW y, Section 6 <br /> OREGON,WI 535, (circle one) <br /> T 05 N. R 09 E <br /> II.Type of Building(check all that apply) Lot# <br /> El 1 or 2 Family Dwelling-Number of Bedrooms 80 Subdivision Name <br /> Block# PARTRIDGE HILL ADDITION TO RAVE <br /> ❑ Public/Commercial-Describe Use City/Village/Town of <br /> CSM Number TOWN OF OREGON <br /> ❑ State Owned-Describe Use <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. ❑ New System 121 Replacement System ❑ Treatment/Holding Tank Replacement Only 0 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 480204-12/22/2014 <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> 121 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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 750 0.6 1250 1350 99.8' <br /> VI.Tank Info Capacity in Total #of Manufacturer Y <br /> Gallons Gallons Units c o d v <br /> m v U u <br /> New Tanks Existing Tanks y o m a s i <br /> a U cn in to it= (� o_ <br /> Septic or Holding Tank 1650 1650 1 Meade ✓ <br /> Dosing Chamber 800 800 _ 1 Crest ✓ _ <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 /> Robert W Martinson Permit application completed online 203148001 (608)575-3055 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 613 N Main St,Oregon,WI 53575- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> ▪ Approved Disapproved <br /> ❑Owner given reason for denial $431.00 12/30/2014 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <br /> To add third cell to existing system to accomodate two additional bedroom addition to house. To convert existing septic tank and add pump <br /> chamber. Plumber must verify condition of existing treatment tanks. <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 />