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commerce.wi.gov County <br /> s <br /> Safety and Buildings Division Dane <br /> I scO n 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 13-2015-00163 <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 <br /> secondary purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> JAMES ELMER HAHN 0909-102-8565-0 <br /> Property Owner's Mailing Address Property Location <br /> 614 GREENFIELD <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW V., NW /4 Section 10 <br /> DEFOREST, WI 53532 (circle one) <br /> T 09 N; R 09 E <br /> 11.Type of Building(check all that apply) Lot# <br /> El I or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> ger <br /> Block# <br /> ❑ Public/Commercial-Describe Use <br /> City/Village/Town of <br /> 13 State Owned-Describe Use CSM Number <br /> 12625 <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 ❑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 /> 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(st) System Elevation <br /> 600 .4 1500 1512 100,99.7,99.4,98.5 <br /> VI.Tank Info Capacity in Total #of Manufacturer m <br /> Gallons Gallons Units a� o a, <br /> New Tanks Existing Tanks c y 2 y <br /> act inv� �) LL (7 a <br /> Septic or Holding Tank 1286 1286 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 /> Plumber's Name(Print) Plumbers 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 $409.00 05/28/2015 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 />