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comrnerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> tfisconsin 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commove Madison,WI 53707-7162 13-2015-00306 <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 7575 COUNTY HIGHWAY C <br /> nrnvide may he uced for cernndary nmmncec in ae,nrdanc a with tie Privacy 1 aw c 1 S(14(1)(nil <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> GILLES C CHAMPAGNE 0910-122-9950-0 <br /> Property Owner's Mailing Address Property Location <br /> 204 MICHELLE LN Govt.Lot <br /> City,State Zip Code Phone Number SE V4 NW / Section 12 <br /> COTTAGE GROVE, WI 53527 T 09 N,R 10 (circle one) <br /> IL Type of Building(check all that apply) Lot# <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 4 . 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use CityNillage/Town of <br /> ❑State Owned-Describe Use CSM Number TOWN OF WINDSOR <br /> 09659 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> ..A. ❑New System ❑Replacement System ❑Treatrnent/Holding Tank Replacement Only REi Other Modification to Existing System(explai <br /> , <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 ❑ . Grade ❑Mound>24 in.of suitable so ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component: ❑Pretreatment device: <br /> • <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 1200 <br /> VI.Tank Info Capacity in Total #of Manufacturer P? . <br /> Gallons . Gallons Units • ,- ° °' o <br /> New Tanks Existing Tanks y 5 2 g ) a P m <br /> tL O in N (n it O a <br /> Septic or Holding Tank 1200 I 1200 1 Meade ✓ <br /> Dosing Chamber 800 ,_ 800 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 /> Steven R De Mars Permit application completed online 6318 (608) 544-4471 <br /> Plumber's Address(Street,City,State,Zip Code <br /> S 8441 Denzer Rd,North Freedom, WI 53951 <br /> VIII.Coun /Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved I:isapproved <br /> ❑Owner given reason for denial $257.00 09/24/2015 Perry Dahl <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Existing S.T./P.C.must be pumped and inspected for compliance. <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 />