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commerce.wl.gov County <br /> Safety and Buildings Division Dane <br /> scOns 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 13-2014-00409 <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 /> govemmental 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 HERBRAND RD <br /> secondary purposes in accordance with the Privacy Law,s.15.04(1 Xm),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> STEWART J BALLWEG 0907-294-9930-0 <br /> Property Owner's Mailing Address Property Location <br /> 9494 DONETTE DR <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE /, SE y, Section 29 <br /> SAUK CITY, WI 53583 (circle one) <br /> T 09 N; R 07 E <br /> II.Type of Building(check all that apply) Lot# <br /> 0 I 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 /> 13580 <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 /> 0 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(sf) System Elevation <br /> 600 .5 1200 1200 92.20,91.30,90.80 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units e o si <br /> New Tanks Existing Tanks co c t y 2 N <br /> 0 2 m a m m <br /> a U tq in to iL C7 a <br /> Septic or Holding Tank 1200 1200 1 Wieser ✓ <br /> Dosing Chamber 800 800 1 Wieser ✓ <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 /> Steve De Mars Permit application completed online 227013 (608)-87-8903 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> S8441 Denzer Rd,North Freedom, WI 53591- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved 0Disapproved <br /> !Downer given reason for denial $431.00 12/09/2014 Perry Dahl <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 />