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commerce.wl.gov County <br /> Safety and Buildings Division Dane <br /> tiisconsin n 201 W. Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00011 <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)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel 4 <br /> GARY M KARLS 0506-052-8590-0 <br /> Property Owner's Mailing Address Property Location <br /> 10795 N PERRY RD Govt.Lot <br /> City,State Zip Code .. Phone Number NW 1�4 NW 14 Section 5 <br /> BLUE MOUNDS, WI 53517 T 05 N; R 06 (cir le one <br /> II.Type of Building(check all that apply) / Lot# <br /> El 1 or 2 Family Dwelling-Number of Bed ooms 4 1 Subdivision Name <br /> j Block# <br /> ❑Public/Commercial-Describe Use City/V illage/Town of <br /> El State Owned-Describe Use CSM Number <br /> 14123 <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(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 E21 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 0.6 1000 2708 103.7 <br /> VI.Tank Info Capacity in Total #of Manufacturer .1 c <br /> m <br /> Gallons Gallons Units a m ° u <br /> New Tanks Existing Tanks 2 c j 2 Tv m N .y <br /> a? a) m <br /> a U in inn Cl) O a <br /> Septic or Holding Tank 1286 1286 1 Meade ✓ <br /> Dosing Chamber 650 650 1 Meade ✓ <br /> VII.Responsibility Statement- 1,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 /> Paul Hardy Permit application completed online 1151 (608) 848-4869 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 7226 Timberwood Dr, Madison, WI 53719 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued - .Issuing Agent Signature <br /> 0 Approved Disapproved <br /> :pawner given reason for denial $1,246.00 01/15/2016 # 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 />