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commerce.wl.gov - County <br /> Safety and Buildings Division Dane <br /> ISV©fl 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 13-2015-00026 <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 /> • <br /> Property Owner's Name Parcel# <br /> MREC VH MADISON LLC 0708-203-4197-0 <br /> Property Owner's Mailing Address Property Location <br /> 6801 SOUTH TOWNE DR <br /> Govt.Lot <br /> City,State Zip Code Phone Number SW % SW % Section 20 <br /> MADISON,WI 53713 (circle one) <br /> T 07 N; R 08 E <br /> II.Type of Building(check all that apply) Lot# <br /> • 1 or 2 Family Dwelling-Number of Bedrooms 5 97 <br /> Subdivision Name <br /> Block# SPRUCE HOLLOW <br /> ❑ Public/Commercial-Describe Use <br /> CityNillage/fown 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 /> 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 /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At Grade ej 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(sf) System Elevation <br /> 750 .6 1250 1425 set at site <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 4,, o y <br /> New Tanks Existing Tanks <br /> Ira o p :? s d m <br /> o <br /> a v ( Cl) to jL t7 a <br /> Septic or Holding Tank 1650 1650 1 meade ✓ <br /> Dosing Chamber 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- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> I✓1 Approved ODisapproved <br /> DOwner given reason for denial $1,246.00 02/06/2015 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 12 x 11 inches in size <br />