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commerce.wi.gov County <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 Comm..'. Madison,WI 53707-7162 13-2015-00234 <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 /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> DONALD C TIERNEY 0911-303-6315-0 <br /> Property Owner's Mailing Address Property Location <br /> 3564 EGRE RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE 1/4 SW 1/, Section 30 <br /> DEFOREST,WI 53532 (circle one) <br /> T 09 N. R 11 E <br /> IL Type of Building(check all that apply) Lot# <br /> ▪ 1 or 2 Family Dwelling-Number of Bedrooms 15 Subdivision Name <br /> Block# BRISTOL GARDENS <br /> ❑ Public/Commercial-Describe Use <br /> CityNillage/Town of <br /> El State Owned-Describe Use CSM Number <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 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 /> 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(sf) System Elevation <br /> 600 0.4 1500 1500 95.9 <br /> VI.Tank Info Capacity in Total #of Manufacturer a <br /> Gallons Gallons Units g U d w <br /> New Tanks Existing Tanks d a „.0 2 m a m m <br /> a 0 to in to a (9 a <br /> Septic or Holding Tank 1286 1286 1 Meade ✓ <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 /> 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 /> El Approved disapproved <br /> Downer given reason for denial $431.00 07/20/2015 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 />