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t(' <br /> commerce.wl.gov County <br /> Safety and Buildings Division Dane <br /> ieco n$i n 201 W. Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Ca m$ Madison,WI 53707-7162 13-2016-00316 <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 /> REISELL LLC 0606-324-9175-0 <br /> Property Owner's Mailing Address Property Location <br /> 1719 REISELL RD Govt.Lot <br /> City,State Zip Code Phone Number SW '/4 SE 1/4 Section 32 <br /> BLUE MOUNDS, WI 53517----------.. (circle one) <br /> \ T 06 N; R 06 E <br /> II.Type of Building(check all that apply) i-ot <br /> 0 1 or 2 Family Dwelling-Number of Bedro s 4 I Subdivision Name <br /> ,/ Block# <br /> ❑Public/Commercial-Describe Use CityNillage/Town of <br /> ❑ State Owned-Describe Use CSM Number <br /> 14330 <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 /> 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 0 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 0.6 1000 1020 90.4 <br /> VI.Tank Info Capacity in Total #of Manufacturer a) .a <br /> Gallons Gallons Units m t j 7 y <br /> New Tanks Existing Tanks u_ o w 2 .tea' . m m <br /> a.c.) coN rn ii0 E_ <br /> Septic or Holding Tank 1250 0 1250 1 Crest ✓ <br /> Dosing Chamber 750 0 750 1 Crest ✓ <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 /> Travis Desmet Permit application completed online 1002082 (608) 424-3014 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 7869 County Highway D, Belleville, WI 53508- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved disapproved <br /> $1,246.00 10/11/2016 James Meyerhofer <br /> ❑Owner given reason for denial <br /> IX.Conditions of Approval/Reason for Disapproval f <br /> r <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 />