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it, <br /> commerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> I c rO 11 S'fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filed in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00032 <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 /> BLATTERMAN BUILT HOMES LLC 0512-054-5633-0 <br /> Property Owner's Mailing Address Property Location <br /> 3472 OLD MEIER RD Govt.Lot <br /> City,State Zip Code Phone Number SW '/e SE / Section 5 <br /> MADISON, WI 53 (circle one) <br /> T 05 N; R 12 E <br /> 11.Type of Building(check all that apply) Lot# <br /> O 1 or 2 Family Dwelling-Number of Bedrooms 3 13 Subdivision Name <br /> Block# BLUE MEADOW ESTATES <br /> ❑Public/Commercial-Describe Use CityNillage/Town of <br /> El 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 ❑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 /> Q 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(se Dispersal Area Proposed(sf) System Elevation <br /> 450 0.4 1125 1125 . 95.2-95.5 <br /> VI.Tank Info Capacity in Total 4 of Manufacturer ?i . <br /> Gallons Gallons Units a 91 V m w u Ts- <br /> CO.5 t New Tanks Existing Tanks o u; 2 Y ,a m <br /> aU (0 i7") to tLO a <br /> Septic or Holding Tank 1000 1000 1 crest ✓ <br /> Dosing Chamber 600 600 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 /> Robert Everson Permit application completed online 226114 (608) -83-7031 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 5285 Lincoln Rd, Oregon, WI 53575- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved pisapproved <br /> ❑Owner given reason for denial $431.00 02/25/2016 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 />