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commerce.wl.gov County <br /> it <br /> Safety and Buildings Division Dane <br /> D SCO h 5 n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00343 <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 /> govemmental 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 /> CLARK W LANGLEY 0911-152-8100-0 <br /> Property Owner's Mailing Address Property Location <br /> 1602 FORDEM AVE UNIT#214 <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE '/ NW '/, Section 15 <br /> MADISON, WI 53704 (circle one) <br /> T 09 N; R 11 E <br /> II.Type of Building(check all that apply) Lot# <br /> Q 1 or 2 Family Dwelling-Number of Bedrooms © 1 Subdivision Name <br /> Illir Block# <br /> ❑ Public/Commercial-Describe Use CityNillage/Town of <br /> ❑State Owned-Describe Use CSM Number <br /> 14333 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. IZI 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 0 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 /> 450 0.6 750 1095.29 98.0(+)21" <br /> VI.Tank Info Capacity in Total 4 of Manufacturer :; e <br /> N p 3 O <br /> Gallons Gallons Units a.- <br /> New Tanks Existing Tanks 2 c 0 2 0 a m m <br /> a0 union co iZO a <br /> Septic or Holding Tank 1000 1000 1 Meade ✓ <br /> Dosing Chamber 650 650 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 /> Steven Tesmer Permit application completed online 227116 (920)478-3033 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> N8458 County Highway 0, Waterloo, WI 53594- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Q Approved Episapproved <br /> QOwner given reason for denial $1,246.00 11/02/2016 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 />