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commerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> ciscc)nsin 201 W. Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of commerce Madison,WI 53707-7162 13-2016-00209 <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 /> THERESE LACASSE 0507-272-9060-8 <br /> Property Owner's Mailing Address Property Location <br /> 8716 RIDGE DR <br /> Govt.Lot <br /> City,State Zip Code Phone Number SW i/4 NW i/4 Section 27 <br /> BELLEVILLE, WI 535 S: (circle one) <br /> T 05 N; R 07 E <br /> H.Type of Building(check all that apply) / Lot <br /> El 1 or 2 Family Dwelling-Number of Bedrop s 4 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use —__,U CityNillagell'own 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. 0 New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. Permit Renewal List previous Permit Number and Date Issued <br /> ❑ ❑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 p 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(st) System Elevation - <br /> 600 0.6 1000 1455 <br /> VI.Tank Info Capacity in Total #of Manufacturer a? <br /> Gallons Gallons Units m o a.°i <br /> New Tanks Existing Tanks m c . 2 ai ai <br /> o N a a m m <br /> Q O Co n to LE 0 a <br /> Septic or Holding Tank 1250 1250 1 Dalmaray ✓ <br /> Dosing Chamber 750 750 1 dalmaray I/ <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 /> Scott Lovelace Permit application completed online 226852 (608) -46-3314 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 9914 County Highway M, Argyle, WI 53504- `-„.... <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued / Issuing Agent Signature <br /> Approved Episapproved <br /> ❑Owner given reason for denial $1,246.00 07/21/2016 James Meyerhofer <br /> IX.Conditions of Approval/Reason for Disapproval <br /> V i <br /> 4`` <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 />