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commerce.wi,gov County <br /> Safety and Buildings Division Dane <br /> 'SCO Fl S I rl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00191 <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. Starr School Rd <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> JEAN E NORDLIE 0510-122-8745-0 <br /> Property Owner's Mailing Address Property Location <br /> N5055 COUNTY ROAD SS <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW '/a NW 14 Section 12 <br /> RIO, WI 53960 (c T 05 N; R 10 rcle one) <br /> II.Type of Building(check all that apply) Lot# <br /> El 1 or 2 Family Dwelling-Number of Bedrooms 4 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use CityNillage/Town of <br /> 0 State Owned Describe Use CSM Number Town of Rutland <br /> 14275 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. Q New System ❑Replacement System El Treatment/Holding Tank Replacement Only ❑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 0 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 1240 100.3 <br /> VI.Tank Info Capacity in Total #of Manufacturer $2 <br /> Gallons Gallons Units m U d N <br /> New Tanks Existing Tanks c w a) m m 2 <br /> Q O u)rn Cl) LL 5 d <br /> Septic or Holding Tank 1250 0 1250 1 Crest ✓ <br /> Dosing Chamber 750 0 750 1 Crest ✓ <br /> VII.Responsibility Statement- I.the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Robert Everson Permit application completed online 226114 (608) -83-7031 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 5285 Lincoln Rd, Oregon, WI 53575- <br /> VIII.County/Department Use Only <br /> 0 Approved disapproved Permit Fee Date Issued Issuing Agent Signature <br /> Downer given reason for denial $1,246.00 07/07/2016 Jacqueline Wescott <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 />