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commerce.wlgov County <br /> Safety and Buildings Division Dane <br /> I <br /> tie co n S!fl 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,WI 53707-7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce 13-2017-00149 <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 <br /> Parcel <br /> MREC VH MADISON LLC <br /> 0708-203-4086-0 <br /> Property Owner's Mailing Address <br /> Property Location <br /> 6801 SOUTH TOWNE DR <br /> Govt Lot. <br /> City,State <br /> JZip Code Phone Number SW 1/4 SW 1/4 Section 20 <br /> MADISON,WI 53713 Not Provided Township: 07 N: Range: 08 E <br /> II.Type of Building(check all that apply) Lot Number Subdivision Name <br /> El 1 or 2 Family Dwelling-Number of Bedrooms: 5 76 <br /> Block Number City/Village/Town of <br /> ❑ Public/Commercial-Describe Use: <br /> CSM Number <br /> ❑ State Owned-Describe Use: <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. Q New System Replacement 0 Other Modification to Existing System(explain) <br /> System ❑ Treatment/Holding Tank Replacement Only <br /> Change of Permit Transfer to List previous Permit Number and Date Issued <br /> B ❑ Permit Renewal 0 <br /> 0 <br /> Before Expiration ❑ Permit Revision plumber New Owner <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At Grade El 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) JSystem Elevation <br /> 750 0.6 1,250 I 1,425 100.2 <br /> Capacity in Gallons N <br /> VI. Tank Info: Total #of c <br /> Gallons Units Manufacturer a [ (j to <br /> New Tanks Existing Tanks _ =° <br /> a'U N .I 6. <br /> EZ <br /> Septic/Holding Tank 1,650 0 1,650 1 Meade if <br /> Dosing Chamber 800 0 800 1 Meade it <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 Plumber's Business Phone <br /> Andrew Meinholz Permit application completed online J 220165 (608)831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee,WI 53597- <br /> VIII.County/Department Use Only <br /> 0 Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑ Owner given reason for denial I $ 1,246.00 06/02/2017 Steven Reese <br /> I <br /> I <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Approved <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 />