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commerce.wi.gov County <br /> it. <br /> Safety and Buildings Division Dane <br /> scnt IT S I fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> ©ePartmer►t of Commerce Madison,WI 53707-7162 13-2016-00227 <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 /> WALDNER CONSTRUCTION INC 0911-193-0111-0 <br /> Property Owner's Mailing Address Property Location <br /> PO BOX 1103 Govt.Lot <br /> City,State Zip Code Phone Number NE 1/4 SW '/4 Section 19 <br /> SUN PRAIRIE, WI 53590 (circle one) <br /> T 09 N; R 11 E <br /> H.Type of Building(check all that apply) Lot# <br /> El 1 or 2 Family Dwelling-Number of Bedrooms 5 11 Subdivision Name <br /> Block# PARKER'S PLACE <br /> ❑Public/Commercial-Describe Use City/Village/Town of <br /> ❑ 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. 12j New System ❑Replacement System ❑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 El 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 750 0.6 1250 1600 107.7',108.5'. <br /> VI.Tank Info Capacity in Total #of Manufacturer :? <br /> Gallons Gallons Units N p N V V 71) 4). <br /> New Tanks Existing Tanks p "m o a m <br /> m <br /> a.c.) co vi co iZLl a <br /> Septic or Holding Tank 1650 1650 1 Meade ✓ <br /> Dosing Chamber 1000 1000 1 Meade ✓ <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 Crosby Permit application completed online 227009 (608) 849-8771 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 7361 Darlin Ct, Dane, WI 53529 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved JJisapproved <br /> Downer given reason for denial $1,246.00 08/04/2016 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <br /> PLAN CORRECTION: "K"=10' "L"=70'. <br /> Protect mound system site and area 15 feet downslope from soil compaction,soil excavation,and vehicular traffic. <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 />