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t:ommerce.wl.gov County <br /> Salfety 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 13-2015-00296 <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 /> nrnvide may he used for secondary nurnnsec in accordance with tl"e Privacy I aw c I S 1)4(11(m) <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> STEVEN L FRAME 0706-304-8810-0 <br /> Property Owner's Mailing Address Property Location <br /> 3565 RYAN RD <br /> . Govt.Lot <br /> City,State Zip Code Phone Number NW '/4 SE '/4 Section 30 <br /> BLUE MOUNDS, WI 53517 (circle one) <br /> . T 07 N; R 06 E <br /> II.Type of Building(check all that apply) Lot# <br /> in I or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use — CityNillage/Town of <br /> ❑State Owned-Describe Use 1 CSM Number <br /> 13988 <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(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 ❑At Grade El 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 /> 450 .6 750 878 890.4 <br /> VI.Tank Info Capacity in I Total #of Manufacturer °) c o <br /> o <br /> Gallons Gallons Units o a) ( <br /> New Tanks Existing Tanks cu c 0 2 wc. 2 m m <br /> aO 0tii w LL C7 d <br /> Septic or Holding Tank 1000 650 1 meade ✓ <br /> . <br /> Dosing Chamber 650 _ 650 _ 1 meade ✓ <br /> VII.Resnonsibilitv Statement- I.the undersiened.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 1151 (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 /> Issuing Agent Signature <br /> yl <br /> I1 Approved disapproved <br /> ❑owner given reason for denial $1,246.00 09/16/2015 Michael Griffin <br /> IX.Conditions of ApprovaUReason 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 /> 1 <br />