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ii <br /> commerce.wigov 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 13-2016-00148 <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)4m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> STUART HODGSON 0606-081-8651-0 <br /> Property Owner's Mailing Address Property Location <br /> 7693 LONE PINE RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW '/ NE 'vi Section 8 <br /> BARNEVELD, WI 53507 (circle one <br /> T 06 N; R 06 E <br /> II.Type of Building(check all that apply) Lot# <br /> El 1 or 2 Family Dwelling-Number of Bedro ms 4 2 Subdivision Name <br /> Block# <br /> El Public/Commercial-Describe Use <br /> CityNillage/fown of <br /> ❑State Owned-Describe Use CSM Number <br /> 11154 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. Ei New System ❑Replacement System 0 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 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 /> 600 0.6 1000 1500 106.8 <br /> VI.Tank Info Capacity in Total #of Manufacturer .8l <br /> Gallons Gallons Units a 2 U w 0 <br /> Tu New Tanks Existing Tanks y o Al a m co <br /> a U cn u) co CC O a <br /> Septic or Holding Tank 1300 0 1300 1 Dalmaray ✓ <br /> Dosing Chamber 750 0 750 1 Dalmaray ✓ <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 /> Timothy Jelle Permit application completed online 227525 (608) 845-7466 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 1330 Fritz Road, Verona, WI 53593- <br /> VIII.County/Department Use Only j'" <br /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved Disapproved <br /> ❑Owner given reason for denial $1,246.00 06/02/2016 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 />