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te. <br /> commerce.wl.gov -isconsCounty <br /> Safety and Buildings Division Dane <br /> / 201 W.Washington Ave.,P.O.Box 7162 ' Sanitary Permit Number(tilled in by Co) — <br /> Department of Commerce rce Madison,WI 53707-7162 13-2016-00023 <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(1 Xm),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name P• arcel# <br /> SAMUEL J HAMILTON 0706-143-9500-9 <br /> Property Owner's Mailing Address ' P• roperty Location <br /> 606 BIRCHWOOD TRL <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE i/4 SW i/4 Section 14 <br /> MT HOREB, WI 53 (circle one) <br /> T 07 N. R 06 E <br /> H.Type of Building(check all that apply) Lot# <br /> l 1 or 2 Family Dwelling-Number of Bedroom 4 S• ubdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> CityNillage/Ibwn 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 ❑Treatment/Holding Tank Replacement Only 0 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: DPretreatment 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 0.6 1000 1463 <br /> VI.Tank Info Capacity in Total #of Manufacturer . <br /> Gallons _ Gallons Units . ,- ° y o <br /> New Tanks Existing Tanks a w 2 a; 2 m m <br /> n.0 in in rn it 0 a <br /> Septic or Holding Tank 1286 1286 1 Meade ✓ <br /> Dosing Chamber 650 650 1 Meade ✓ <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 /> Gary Meinholz Permit application completed online 222318 (608) 831-8103 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 6813 County Highway K, Waunakee, WI 53597- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Er Approved disapproved <br /> [owner given reason for denial $1,246.00 02/15/2016 Brandon Macomber <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 />