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titcommerce.wi.gov County <br /> 1 Safety and Buildings Division Dane <br /> SCO n S 1 n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2015-00258 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submiss on of this form to the appropriate <br /> governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for Project Address(if different than mailing) <br /> state-owned POWTS are submitted to the Department of Commerce.Personal information you <br /> nrnvirie may he'iced fnr cernnriary numncec in arrnrrianre with the Privacy 1 aw c 15 64(11(ml <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> GARY M KARLS 0708-194-7350-0 <br /> Property Owner's Mailing Address Property Location <br /> 10795 N PERRY RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE 1/4 SE 1/4 Section 19 <br /> BLUE MOUNDS, WI 53517 (circle one) <br /> Type of Building T 07 N R 08 E <br /> II.T <br /> yp g(check all that apply) Lot# <br /> 0 I or 2 Family Dwelling-Number of Bedrooms 4 1 Subdivision Name <br /> Block# KARLS SUBDIVISION <br /> ❑Public/Commercial-Describe Use City/V illage/Town of <br /> ❑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. 0 New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explai <br /> List previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumbe ❑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 ❑Al Grade 0 Mound>24 in.of suitable so ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component: ❑Pretreatment device: <br /> V.Dispersal/Treatment Area Information: <br /> — <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf Dispersal Area Required(sf) Dispersal Area Proposed(sf System Elevation <br /> 600 .6 1000 1200 100.3 <br /> VI.Tank Info Capacity in Total #of Manufacturer 21 <br /> Gallons Gallons Units a 2 ° d 3 <br /> New Tanks Existing Tanks y o 0 2 a m m <br /> a- C.) incq CO iZ0 d <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.Count /Department Use Only <br /> 0 Approved Permit Fee Date Issued Issuing Agent Signature <br /> pp IJisapproved <br /> ❑owner given reason for denial $607.00 08/12/2015 Michael Griffin <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 />