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commerce.wigov 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 Commerce Madison,WI 53707-7162 13-2015-00314 <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 /> govemmental 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 may he iced fnr cernndary numncec in arrnrrianre with the Privacy I mu c 15(14(11(m) <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> MEADOW ROAD LLC 0708-324-4012-0 <br /> Property Owner's Mailing Address Property Location <br /> 1301 TOWERING PINES RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number SW '/, SE '/, Section 32 <br /> GALLATIN GATEWAY, MT 597 (circle one) <br /> T 07 N, R 08 E <br /> II.Type of Building(check all that apply) Lot# <br /> 0 I or 2 Family Dwelling-Number of Bedroom 5 2 Subdivision Name <br /> Block# MEADOW ROAD ESTATES <br /> El Public/Commercial-Describe Use City/VillagefTown 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 12 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explai <br /> List previous Permit Number and Date Issued <br /> 13. ❑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 ❑At 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/If reatment Area Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf Dispersal Area Required(sf) Dispersal Area Proposed(sf System Elevation <br /> 750 .6 1250 1555 see plans <br /> VI.Tank Info Capacity in Total #of Manufacturer c <br /> Gallons Gallons_ Units ` ° °= <br /> New Tanks Existing Tanks d o 2 m . m 2 <br /> o o in (O co u. 5 a <br /> Septic or Holding Tank 1650 1650 1 meade ✓ <br /> Dosing Chamber 800 800 1 meade ✓ <br /> VII.Resaonsibility 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 /> Paul Hardy Permit application completed online 1 151 (608) 848-4869 <br /> Plumber's Address(Street,City,State,Zip Code <br /> 7226 Timberwood Dr, Madison, WI 53719 <br /> VIII.Count /Department Use Only <br /> O Approved IJJisapproved <br /> ❑Owner given reason for denial $1,246.00 09/30/2015 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 />