Laserfiche WebLink
commerce.wl.gov County <br /> Safety and Buildings Division Dane <br /> cC 'O f S I fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by(2o) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00310 <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 /> PECQUEX FAMILY JT REV LIVING TR 0806-291-9730-0 <br /> Property Owner's Mailing Address Property Location <br /> 714 FOREST EDGE DR Govt.Lot <br /> City,State Zip Code Phone Number SE '/a NE / Section 29 <br /> MAZOMANIE, WI 535. (circle one) <br /> Type of Building pp T 08 N; R 06 E <br /> II.T <br /> yp g(check all that a I L. # <br /> — <br /> Q I or 2 Family Dwelling-Numbe . B oms 4 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use City/Village/Town of <br /> CI 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 /> 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 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 .6 1000 1875 96.5 <br /> VI.Tank Info Capacity in Total #of Manufacturer . <br /> Gallons Gallons Units 0 m 2. <br /> New Tanks Existing Tanks c g 2 Y m <br /> a.0 co in u) it(7 a <br /> Septic or Holding Tank 1286 0 1286 1 Meade ✓ <br /> Dosing Chamber 650 0 650 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 R Crosby Permit application completed online 227009 (608) 849-8771 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 7361 Darlin Drive, Dane, WI 53529- <br /> VIII.County/Department Use Only <br /> Approved disapproved Permit Fee Date Issued Issuing Agent Signature <br /> Downer given reason for denial $1,246.00 10/07/2016 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Using a Rizzy Flout dose system. <br /> Protect mound system site and area 15 feet downslope from soil compaction,soil excavation,ad 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 />