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commerce.wi.gov county <br /> Safety and Buildings Division Dane <br /> SCO11 S 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 <br /> 13-2015-00054 <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 2200 COUNTY HIGHWAY T <br /> secondary purposes in accordance with the Privacy Law,s.15.04(I)(m),Stets. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel a <br /> BRIAN ACKER 081 I I-)0 15-0 <br /> Property Owner's Mailing Address P o}''crlt LOCInion <br /> 550 OLD INDIAN MOUND TRL <br /> Co■ Lot <br /> City,State Zip Code Phone Number NW 1/4 NI; lA Section 22 <br /> SUN PRAIRIE, WI 53590 nirrle one) <br /> T 08 N: R II E <br /> II.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms 4 1 Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use <br /> City/Village/Town of <br /> 12 State Owned-Describe Use CSM Number TOWN OF SUN PRAIRIE <br /> 10271 <br /> III.Type of Permit:(Check only one box on line A.Complete line It if applicable) <br /> A. 10 New System ❑Replacement System ❑ Ti eatmcnt/t bId)mg Tank Replacement On!) Other AIndilicatiun a li�isiing S�se.n(.:gip:,:of <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 /> El 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 /> 600 0.4 1500 1512 97.4-96.4 <br /> VI.Tank Info Capacity in Total II of Manufacturer u, <br /> Gallons Gallons Units a <br /> New Tanks Existing Tanks �° ? i <br /> E.' a m m <br /> a` U io v ui S 7 ' <br /> Septic or Holding Tank 1286 1286 1 Meade ✓ <br /> Dosing Chamber 650 650 1 Meade ✓ <br /> VII.Responsibility Statement-I,the undersinned,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 /> Approved ❑Disapproved <br /> Downer given reason for denial $431.00 03/19/2015 James Meyerhofer <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Shallow system,soil must be dry for installation <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 />