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commerce.wi.gov <br /> County <br /> 1 sco n s;n Safety and Buildings Division Dane <br /> 201 W.Washington Ave.,P.O.Box 7162 anitary 'ermit lum.-r I ea in ,y o <br /> Department of Commeroe Madison,WI 53707-7162 <br /> 13-2016-00139 <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 <br /> 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.As.lication Information-Please Print All Information <br /> Property Owner's Name <br /> MREC VH MADISON LLC Parcel# <br /> Property Owner's Mailing Address 0708-203 4208-0 <br /> 6801 SOUTH TOWNE DR Property Location <br /> Code Govt.Lot <br /> City,State <br /> Zip Phone Number <br /> MADISON, WI 53713 SW '/4 SW /4 Section 20 <br /> II.Type (circle one) <br /> ype of Building(check all that apply) Lot# T 07 N; R 08 E <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 5 98 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# SPRUCE HOLLOW <br /> CityNillage/rown of <br /> Um <br /> ❑State Owned-Describe Use <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> II <br /> 0 New System ❑Replacement System o Tank Replacement Only <br /> Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision List previous Permit Number and Date Issued <br /> Before Expiratio ❑Change of Plumber ❑Permit Transfer to <br /> New Owner - <br /> apply) <br /> IV.Type of POWTS System/Component/Device:(check all that a l <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: <br /> ['Pretreatment device: <br /> V.Dis s ersal/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 <br /> VI.Tank Info 1350 <br /> Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 0 a <br /> New Tanks Existing Tanks <br /> co o O t 2 ct <br /> 20 a; 2 am m <br /> Septic or Holding Tank a 0 co 175 u_O d <br /> 1650 1650 1 Meade <br /> Dosing Chamber V/ ==== <br /> 800 800 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 <br /> Andrew Meinholz PRS Number Business Phone Number <br /> Permit application completed online 220165 <br /> Pum,-rsAa'ress treet, tty, tate,Zip ose (608) 831-8103 <br /> 6813 County Highway K, Waunakee, WI 53597- <br /> VIII.County/Department Use Only <br /> 0 Approved disapproved Permit ee late ssue• Issuing •gent ignature <br /> ['Owner given reason for denial $1,246.00 05/31/2016 James Meyerhofer <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 />