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commerce.wigov County <br /> Safety and Buildings Division Dane <br /> 'SCO fl S 1 fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00130 <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 /> JAMIE L FIEBER 0708-301-6645-0 <br /> Property Owner's Mailing Address Property Location <br /> 9407 ANCIENT OAK LN Govt.Lot <br /> City,State Zip Code Phone Number SE i/4 NE i/4 Section 30 <br /> VERONA, WI 53593 (circle one) <br /> T 07 N; R 08 E <br /> H.Type of Building(check all that apply) Lot# <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 4 5 Subdivision Name <br /> Block# CHERRYWOOD FOREST <br /> ❑ Public/Commercial-Describe Use <br /> CityNillage/Town of <br /> ID 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. Ei 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 [.'7p 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 1218 105.5, 106.2 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .0 o <br /> o , u <br /> New Tanks Existing Tanks y c w 2 m <br /> a O iD in to IL 5 d <br /> Septic or Holding Tank 1200 0 1200 1 Meade ✓ <br /> • <br /> Dosing Chamber 800 0 _ 800 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 /> 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 QJisapproved <br /> ❑Owner given reason for denial $1,246.00 05/26/2016 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 />