Laserfiche WebLink
commerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> i sco n s I n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00084 <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# <br /> DONALD C TIERNEY 0911-303-6304-0 <br /> Property Owner's Mailing Address Property Location <br /> 3564 EGRE RD <br /> Govt.Lot <br /> City,State <br /> Zip Code Phone Number SE i/4 SW y4 Section 30 <br /> DEFOREST, WI 53532 (circle one) <br /> T 09 N; R 11 E <br /> II.Type of Building(check all that apply) Lot# <br /> PI or 2 Family Dwelling-Number of Bedrooms 5 14 Subdivision Name <br /> Block# BRISTOL GARDENS <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. 0 New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to List previous Permit Number and Date Issued <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 0 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 /> 750 0.6 1250 1350 97.7 <br /> VI.Tank Info Capacity in Total 4 of Manufacturer 81 <br /> Gallons Gallons Units . o aa) <br /> ca New Tanks Existing Tanks <br /> N V m 2 <br /> C y ` a) 0 N ca 03 <br /> Q O coin to iL-0 a <br /> Septic or Holding Tank 1650 0 1650 1 Meade ✓ <br /> Dosing Chamber 800 0 800 1 Meade ✓ <br /> VII.Responsibility Statement- I.the undersiened,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 /> Andrew Meinholz Permit application completed online 220165 (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 /> Approved Permit Fee Date Issued Issuing Agent Signature <br /> g� pp disapproved <br /> ❑Owner given reason for denial $1,246.00 04/28/2016 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Protect mound system site and area 15 feet downslope from soil compaction,soil excavation,and vehicular traffic. <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 />