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commerce.wigov <br /> Safety and Buildings Division am <br /> tfisconsin 201 W. Washington Ave.,P.O.Box 7162 Sanitary Permit Number lied in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00225 <br /> Sanitary Permit Application e Transaction Numbe <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate la <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 3311 SARACEN WAY <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 /> ROBERT M NEWCOMB 0708-323-0133-0 <br /> Property Owner's Mailing Address Property Location <br /> 8574 ARBOR TRACE DR <br /> Govt.Lot <br /> City,State Zip C. Phone Number NE 1/4 SW i/, Section 32 <br /> VERONA, WI 53 (circle <br /> 07 N; R 08 E <br /> II.Type of Building(check all that apply) Lot# <br /> El 1 or 2 Family Dwelling-Number of Bedroo 4 33 Subdivision Name <br /> Block# GLACIERS END <br /> ❑Public/Commercial-Describe Use <br /> City/Village/Town of <br /> Now- <br /> ❑ State Owned Describe Use CSM Number TOWN OF 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 /> 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 /> El Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At Grade ❑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 0.4 1500 1512 102.5-101.5 <br /> VI.Tank Info Capacity in Total #of Manufacturer a? <br /> Gallons Gallons Units a 2 ° <br /> New Tanks Existing Tanks o m 2 uy m 2 <br /> aU coin to ir_Q E <br /> Septic or Holding Tank' 1286 1286 1 Meade ✓ <br /> Dosing Chamber <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 /> Andrew Meinholz Permit application completed online 220165 (608) 831-8103 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 6813 County Highway K, Waunakee, WI 53597- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved Disapproved <br /> ❑owner given reason for denial $409.00 08/08/2016 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 />