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commerce.wi.goV County <br /> Safety and Buildings Division Dane <br /> tii SCO fS;fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2015-00033 • <br /> State Transaction Number <br /> Sanitary Permit Application <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(1Xm),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> GOFF CONSTRUCTION&REAL ESTATE INC 0708-301-6755-0 <br /> Property Owners Mailing Address Property Location <br /> 4703 SUNSET RIDGE DR Govt.Lot <br /> City,State Zip Code Phone Number SE '/4 NE '/4 Section 30 <br /> MIDDLETON,WI 53562 (circle one) <br /> T 07 N; R 08 E <br /> II.Type of Building(check all that apply) Lot# <br /> El 1 or 2 Family Dwelling-Number of Bedrooms <br /> 5 15 Subdivision Name <br /> Block# CHERRYWOOD FOREST <br /> ❑ Public/Commercial-Describe Use City/Village/Town of <br /> CSM Number Town of Middleton <br /> ❑ State Owned-Describe Use <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> ❑Other Modification to Existing System(explain) <br /> A. 0 New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only <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 /> O Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank DOther 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 .4 1875 1890 see plans <br /> VI.Tank Info Capacity in Total #of Manufacturer Y, <br /> Gallons Gallons Units .0 ° d u <br /> !„�, u U o N d w a <br /> New Tanks Existing Tanks 2 oo a 2 :1 a m m <br /> a. 0 u) rn LLCM a. <br /> Septic or Holding Tank 1650 1650 1 meade ✓ <br /> Dosing Chamber <br /> VII.Responsibility Statement-I.the undersigned.assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(Print) Plumber's 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 /> O Approved Disapproved <br /> $409.00 02/18/2015 Michael Griffin <br /> Downer given reason for denial <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 />