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commerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> tiisconsin 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2015-00263 <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 Project Address(if different than mailing) <br /> state-owned POWTS are submitted to the Department of Commerce.Personal information you <br /> nrnvide max/he raced fnr cernndary nmmncec in arm-dance with the Privacy 1 aw s 15 04(11(ml <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> POGO BELLE LLC 0808-092-0695-0 <br /> Property Owner's Mailing Address Property Location <br /> 6065 WHIPPOORWILL RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE 1/4 NW 1/4 Section 9 <br /> CROSS PLAINS, WI 53528 (circle one) <br /> T 08 N; R 08 E <br /> II.Type of Building(check all that apply) Lot# <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name <br /> Block# <br /> El Public/Commercial-Describe Use Office Building <br /> City/Village/Town of <br /> ❑State Owned-Describe Use CSM Number <br /> 14038 <br /> Ill.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(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 /> El Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At Grade ❑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 /> Design Flow(gdp) Design Soil Application Rate(gpdsf Dispersal Area Required(sf) Dispersal Area Proposed(sf System Elevation <br /> 600 .5 1200 1200 92.6 <br /> - <br /> VI.Tank Info Capacity in Total I #of Manufacturer ai e <br /> Gallons Gallons Units n `r O s, `%' <br /> New Tanks Existing Tanks m e a) ? m a to m <br /> a0 coi <br />