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commerce.wi.gov - County <br /> Safety and Buildings Division Dane <br /> 7�+►co n Q'n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department ot Commerce Madison,WI 53707-7162 13-2015-00370 <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 2626100 <br /> governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-owned Project Address(if different than mailing) <br /> POWTS are submitted to the Department of Commerce.Personal information you provide may be used for 6925 ELDER LN <br /> secondary purposes in accordance with the Privacy Law,s. 15.04(IXm),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> THOMAS J BOBEK 0911-224-9510-0 <br /> Property Owner's Mailing Address Property Location <br /> 3115 HAWKS HAVEN TRL <br /> Govt.Lot <br /> City,State Zip Code - Phone Number SE '/4 SE 1/4 Section 22 <br /> DEFOREST, WI 53532 (circle one <br /> T 09 N; R 11 E <br /> U.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 restaurant/bar CityNillage/Town of <br /> ❑State Owned-Describe Use CSM Number TOWN OF BRISTOL <br /> 13936 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. ❑New System El Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑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 ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component: OPretreatment device: ATU <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 /> 3669 0.8 4586.25 4595.40 <br /> VI.Tank Info Capacity in Total #of Manufacturer 2 <br /> Gallons Gallons Units . tj w u <br /> New Tanks Existing Tanks y 5 2 . m m <br /> _O in in ii 0 a <br /> Septic or Holding Tank 2000 2000 1 wieser ✓ <br /> Dosing Chamber 1000 _ 1000 1 wieser _ V <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 Tesmer Permit application completed online 227116 (920)478-3033 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> N8458 County Highway 0, Waterloo, WI 53594-9403 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved Episapproved <br /> ❑Owner given reason for denial $1,237.00 12/01/2015 James Meyerhofer <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Downsized mound with atu,high strength waste,grease interceptor <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 />