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Commerce.wl.gov - County <br /> Safety and Buildings Division Dane <br /> tfisconsin 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department ct Commerce Madison,WI 53707-7162 13-2015-00092 <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 7590 KINDSCHI 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 ti <br /> ANDREW R LOVICK 0910-112-9000-8 <br /> Property Owner's Mailing Address Property Location <br /> 4319 HAWK TRL <br /> Govt.Lot <br /> City,State Zip Code Phone Number SW y4 NW y, Section 11 <br /> DEFOREST,WI 53532 (circle one) <br /> T 09 N. R 10 E <br /> II.Type of Building(check all that apply) 1 Lotti <br /> El 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> ' - Block# <br /> ❑ Public/Commercial-Describe Use <br /> City/Village/Town of <br /> 0 State Owned-Describe Use CSM Number TOWN OF WINDSOR <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. ❑ New System El 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 /> 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 ❑Other Dispersal Component: ❑Pretreatment device: <br /> V.DispersaVFreatment Area Information: <br /> Design Flow(gdp) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 .4 1 125 1 134 94,7,94.8,94.9 <br /> VI.Tank Info Capacity in Total S of Manufacturer y <br /> Gallons Gallons _ Units a p o d <br /> New Tanks Existing Tanks c y y ,m _ m <br /> aO vw <br /> rn it a <br /> Septic or Holding Tank 1000 1000 1 Meade V <br /> Dosing Chamber 650 650 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 /> Scott Baumann Permit application completed online 231729 (608)-74-8618 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W7550 State Road 16, Pardeeville, WI 53954-9520 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> El Approved ODisapproved <br /> Downer given reason for denial $431.00 04/15/2015 Perry Dahl <br /> IX.Conditions of ApprovalReason for Disapproval <br /> Existing S.T.must be properly abandoned. <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 />