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commerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> isco n s i n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Col <br /> Department of Commerce Madison.WI 53707-7162 13-2015-00077 <br /> Sanitary Permit Application Stale 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 3853 PHEASANT POINT CT <br /> secondary purposes in accordance with the Privacy Law,s. 15.04(I)(m),Slats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel <br /> PREMIER BUILDERS INC 0708-1 <br /> Property Owner's Mailing Address Property Location <br /> 102 N HOLIDAY DR <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW 'A SW V, Section 19 <br /> WAUNAKEE,WI 53597 (circle ono <br /> T 07 N; R 08 E <br /> II.Type of Building(check all that apply) Lots! <br /> RI I or 2 Family Dwelling-Number of Bedrooms 4 4 Subdivision Name <br /> Block/I PHEASANT POINT I <br /> ❑ Public/Commercial-Describe Use <br /> City/Village/Town of <br /> ❑ State Owned-Describe Use CSM Number TOWN OF MI DDL ETON <br /> lit.Type of Permit:(Check only one box on line A.Complete line Ii if applicable) <br /> A. ✓] New System []Replacement System [] Treatmencl folding Tank Replacement Only. ❑ )'har.Atorlilicmion io Existing 5�aa�n levy en; <br /> List previous Permit Number and Date Issued <br /> B. ❑Permit Renewal [] Permit Revision [] Change of Plumber 0 Permit Transfer to <br /> Before Expiration New Owner - <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> El Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At Grade 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> 0 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(si) Dispersal Area Proposed(sf) System Elevation <br /> 600 .6 1000 1 125 93.3 <br /> VI.Tank Info Capacity in 'total 11 of Manufacturer <br /> Gallons Gallons Units 2 o <br /> g Tanks � <br /> Existing E a; ❑ m m <br /> New Tanks <br /> c) in iii ti C7 <br /> Septic or Holding Tank 1286 1286 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 /> Steve R Crosby Permit application completed online 227009 (608) 849-8771 <br /> Plumbers Address(Street,City,State,Zip Code) <br /> 7361 Darlin Drive,Dane, WI 53529- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Siga:nrr <br /> 0 Approved ['Disapproved <br /> Downer given reason for denial $431.00 04/06/2015 MichaelGriflln <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 />