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Commerce.W1.gov County <br /> Safety and Buildings Division Dane <br /> tfisconsin 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00065 <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),Slats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel 4 <br /> NATHAN A WEITZEL 0808-043-4222-0 <br /> Property Owner's Mailing Address Property Location <br /> E7907 E LAKE VIRGINIA RD <br /> City,State Zip Code Phone Number Govt.Lot i <br /> SW /a SW /, Section 4 <br /> REEDSBURG, WI 53959 T 08 N; R 08 <br /> (circle one <br /> II.Type of Building(check all that apply) Lot# <br /> 0 I or 2 Family Dwelling-Number of Bedr oms 4 12 <br /> Subdivision Name <br /> Block# SPRINGFIELD RIDGE <br /> ❑Public/Commercial-Describe Use . <br /> CityNillage/Town of <br /> ' <br /> ❑ State Owned-Describe Use � ;� • CSM Number <br /> �X, a <br /> III.Type of Permit:(Check only one box on line A.Compl e I B if applic le <br /> A. Ej 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 /> El 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: ❑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 .40 1500 1512 93.0' 94.0' 95.0' <br /> VI.Tank Info Capacity in Total 4 of Manufacturer II <br /> Gallons Gallons Units a m o I ii <br /> New Tanks Existing Tanks m o i 2 . . m <br /> n_U 0in (0 it 0 E <br /> Septic or Holding Tank 1286 0 1286 1 Meade ✓ <br /> Dosing Chamber 0 0 0 0 0 <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 /> Steve R Crosby Permit application completed online 227009 (608) 849-8771 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 7361 Darlin Drive, Dane, WI 53529- <br /> VIII.County/Department Use Only <br /> 0 Approved disapproved Permit Fee Date Issued Issuing Agent Signature <br /> Downer given reason for denial $409.00 04/06/2016 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 />