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Commerce.WI.gov County <br /> Safety and Buildings Division Dane <br /> Misconsin 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Madison,WI 53707-7162 <br /> Deportment of Cotnmorce 13-2016-00198 <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. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> JAMES A WINTER 0512-054-7046-0 <br /> Property Owner's Mailing Address Property Location <br /> 584 MERRIFIELD RD <br /> City,State Govt.Lot <br /> Zip Code Phone Number SE '/4 SE i/4 Section <br /> EDGERTON, WI 53534 T 05 N; R 12 (circle one) <br /> II.Type of Building(check all that apply) Lot# <br /> lo 1 or 2 Family Dwelling-Number of Bedrooms 3 26 Subdivision Name <br /> Block# BLUE MEADOW ESTATES <br /> ❑Public/Commercial-Describe Use <br /> CityNillage/Town of <br /> ID State Owned-Describe Use CSM Number <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. El New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to List previous Permit Number and Date Issued <br /> Before Expiration New Owner - <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> ro Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in of suitable soil <br /> ❑Holding Tank Daher 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 /> 450 0.4 1125 1128 96.0' <br /> VI.Tank Info Capacity in Total #of Manufacturer m <br /> Gallons Gallons Units o.cp O N <br /> y New Tanks Existing Tanks w e N� O <br /> N (P .D N f0 <br /> a O V)Cn u) it O d <br /> Septic or Holding Tank 1000 1000 1 Dalmaray ✓ <br /> Dosing Chamber <br /> 600 600 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) Plumbers Signature MP/MPRS Number Business Phone Number <br /> Brad Fuller Permit application completed online <br /> PP P 220343 (608) 873-7098 <br /> Plumbers Address(Street,City,State,Zip Co e) <br /> VIII.County/Department Use Only <br /> Approved Permit Fee Date Issued Issuing Agent Signature <br /> El pp Episapproved <br /> ['Owner given reason for denial $431.00 07/13/2016 Richard Herro <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 />