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r <br /> j <br /> commerkwt.go„S E P 1 7 $ ety and Buadings Division t Comity Dane <br /> 20 uhington Ave.,P.O.Box 7162 <br /> Q Madison,WI 5 3 70 7-7 1 62 Sanitary Permit Number(to be filled in by Co.) <br /> Department tn.Dscon 57 S / 14. 6 <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 governmental <br /> unit is required prior to obtaining a sanitary permit. Note•. Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. 7528 Felton Drive <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name, Parcel a <br /> Scott&ReneB Endres 0708-323-6166-0 <br /> Property Owner's Mailing Address Property Location <br /> 8540 Greenway Blvd. Unit 210 Govt.Lot <br /> City,State Zip Code Phone Number SE V., SW V., section 32 <br /> Middleton,WI 53562 669-4343 (circle one) <br /> T 7 N; R 8 E or W <br /> II.Type of Building(check all that apply) Lot a <br /> El I or 2 Farrily Dwelling—Number of Bedrooms 4 16 Subdivision Name <br /> Block a Glacier's Woods <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Ntmn ❑Village of <br /> I2 Town or Middleton <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A" ®New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> i <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> GI 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(explain) ❑Pretreatment Device(explain) <br /> V.DispersaVireatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(af) System Elevation <br /> 600 0.4 ._ I SOO _ -trst,e, I S!2— 94.8,94.5,94.2, 93.9' <br /> VI.Tank Info Capacity in Total It of Manufacturer <br /> Gallons Gallons Units $u .a <br /> u <br /> New Taab Existing Tartu o B 2 c , a 'e <br /> I t rn Y in 1i P. <br /> Septic or Holding Tank 1200 1200 1 Meade x <br /> Dosing Chamber 800 , 800 _ 1 _ Meade _ x <br /> VU.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI t' Signature ()`- MP/MPRS Number Business Phone Number <br /> _ La Vern )'awl 7....e^.4.- H P �.;� '3Y 7/.l-iii <br /> Plumber's Address(Street,City,State,Zip Code)n / //,,'' <br /> C .3: --5-(r, Kos}en%ck_ /i 0c.01, P/4jn ` - S 5'3577 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing :ent Si: ore <br /> )Approved ❑Disapproved <br /> // ❑Owner Given Reason for Denial S no/- --- q/l <br /> i q/o g <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attuh to complete plan for the system and submit to the County only on paper not less than 0 rn x t 1 Inches la size <br /> p8- 262-9 <br /> SBD-6398(R.01/07)Valid thru 01/09 <br /> CH-K- 144g6i <br />