Laserfiche WebLink
commerce.wlgov County <br /> Safety and Buildings Division Dane <br /> ttisconsin 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2015-00212 <br /> State Transaction Number <br /> Sanitary Permit Application <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 /> 964 COUNTY HIGHWAY T <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 a <br /> PETER R BULLWINKEL 0811-173-8640-0 <br /> Property Owner's Mailing Address Property Location <br /> 964 COUNTY HIGHWAY T Govt.Lot <br /> City,State Zip Code Phone Number NW 1/4 SW y4 Section 17 <br /> MARSHALL, WI 53559 (circle one) <br /> T 08 N; R II E <br /> II.Type of Building(check all that apply) © Lot# <br /> El I or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use <br /> City/Village/Town of <br /> ❑ State Owned-Describe Use -_ CSM Number TO OF MEDINA <br /> _ <br /> 13977 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. El New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Mo 177, <br /> List previous 14.A.--0� l / <br /> B. ❑Permit Renewal ❑ Permit Revision 0 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• <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(s1) Dispersal Area Proposed(sf) System Elevation <br /> 750 0.4 1875 1880 98.5-97.0 <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units o ra <br /> New Tanks Existing Tanks d o y y `y w <br /> o <br /> a_ O in in (n t1 O a <br /> - <br /> Septic or Holding Tank 1650 1650 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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Steven Tesmer Permit application completed online 227116 (920)478-3033 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> N8458 County Highway 0,Waterloo, WI 53594- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved ['Disapproved <br /> ['Owner given reason for denial $409.00 07/07/2015 James Meyerhofer <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 />