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it. <br /> commerce.wi.gov I County <br /> Salty and Buildings Division Dane <br /> SC C)n S n 201 W. ashington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2015-00272 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submissi n of this form to the appropriate <br /> governmental unit is required prior to obtaining a sanitary permit. ote:Application forms for Project Address(if different than mailing) <br /> state-owned POWTS are submitted to the Department of Commerc .Personal information you <br /> nrnvide may he iced fnr ceenndary nmmncec in arrnrdanre with th Privacy l aw c 15 04(11(m) <br /> I.Application Information-Please Print All Informatio�t <br /> Property Owner's Name Parcel# <br /> PAUL E MARKQUART 0610-284-8710-0 <br /> Property Owner's Mailing Address Property Location <br /> 481 MEDINA ST <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW 'V4 SE '/a Section 28 <br /> OREGON, WI 5359 T 06 N.R 10 (cir leone) <br /> II.Type of Building(check all that apply) ` Lot# <br /> RI I or 2 Family Dwelling-Number of Bedroom 4 1 Subdivision Name <br /> \ i Block# <br /> ❑Public/Commercial-Describe Use City/V illage/town of <br /> ❑ State Owned-Describe Use CSM Number <br /> 05737 <br /> III.Type of Permit: (Check only one box on line A.Complete line B if applicable) <br /> A. EJ 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 Exoiration New Owner - <br /> IV.Type of POWTS System/Component/Device: (check all that apply) <br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At Grade ❑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 /> 600 .4 1500 1500 95.4/94.9 <br /> VI.Tank Info Capacity in Total #of Manufacturer w� � � <br /> Gal ons Gallons Units t °= v,65 <br /> New Tanks Existing Tanks o „ 2 m a m m <br /> aU in in v) it (.9 a <br /> Septic or Holding Tank 1250 1250 1 crest ✓ <br /> Dosing Chamber ' 750 750 1 crest ✓ <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 /> Ken Haugen Permit application completed online 224121 (608) 205-0238 <br /> Plumber's Address(Street,City,State,Zip Code <br /> 317 W Broadway St, Stoughton, WI 53589- <br /> VIII.Count /Department Use Only <br /> 0 Approved (]disapproved it Per Fee Date Issued Issuing Agent Signature <br /> ❑owner given reason for denial $ it Fee 08/27/2015 Michael Griffin <br /> IX.Conditions of Approval/Reason for Disapproval <br /> i <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 />