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tommerce.wi.gov County <br /> i Safety and Buildings Division Dane <br /> i scores I n 201 W. Washington Ave., P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> D of Commerce Madison,WI 53707-7162 Department 13-2016-00008 <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 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 <br /> secondary purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel it <br /> THE HEFFRON COMPANY INC 0907-183-6143-0 <br /> Property Owner's Mailing Address Property Location <br /> 200 PRAIRIE ST STE 200 Govt.Lot <br /> City,State Zip Code Phone Number SE '/4 SW '/4 Section 18 <br /> PRAIRIE DU SAC, WI 53578 (circle one <br /> T 09 N; R 07 E <br /> II.Type of Building(check all that apply) Lot# <br /> O 1 or 2 Family Dwelling-Number of Bedrooms 3 23 <br /> Subdivision Name <br /> Block# BLACKHAWK FIELDS <br /> ❑ Public/Commercial-Describe Use <br /> CityNillage/Town 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. ❑New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> Reconnection, <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: ❑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 /> VI.Tank Info Capacity in Total #of Manufacturer 2 D <br /> ca Gallons Gallons Units , ° <br /> New Tanks Existing Tanks c m 2 a m m <br /> a U (re in to U (D a <br /> Septic or Holding Tank <br /> Dosing Chamber <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 /> Brian Elsjng Permit application completed online 1005477 (608) 432-4687 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> E10257, Greimel, Baraboo, WI 53913 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> EI Approved JJisapproved <br /> ❑Owner given reason for denial $257.00 01/08/2016 Brandon Macomber <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Deed restriction regarding number of bedrooms must be filed for this house. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2x 11 inches in size <br />