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oAaTirery,,0 <br /> County <br /> 6' i;4,: Industry Services Division Dane <br /> a f.„4",...::-.,4 >t K, , 1400 E Washington Ave <br /> ry <br /> P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> %.,?, � � Madison,WI 53707-7162 3-2020-00313 <br /> \SSIOA <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383,21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law.s. 15.04(1)(m),Stats. Berlin Rood <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name <br /> Justin &Amanda Pries Parcel# <br /> 0812-053-9030-0 <br /> Property Owner's Mailing Address <br /> 5709 Oxbow BND Property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number SW%,SW%, Section 05 <br /> Madison,WI 53716 <br /> (circle one) <br /> H.Type of Building _ T 08 N ; R 12 E or W <br /> Yp (check all that apply) 3 Lot# <br /> 10 1 ort Family Dwelling-Number of Bedrooms <br /> Subdivision Name <br /> 0 Public/Commercial-Describe Use Block# <br /> 0 State Owned-Describe Use 0 City of <br /> CSM Number 0 Village of <br /> �4 Town of Medina <br /> III.Type of Permit: (Check only one box on fine A. Complete line B if applicable) <br /> A. ® Neto System 0 Replacement Systemi <br /> p Y 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal 0 Permit Revision 0 Change of <br /> Before Expiration ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized.In-Ground 0 Pressurized In-Ground , <br /> ❑ HoldingTankl(.�hlAt-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> DesignFlow(gpd) Design Soil Application Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> qt-S C) Rate(gpdsf) <br /> VI.Tank Info Capacity in <br /> Gallons Total 4 of .o <br /> Gallons Units Manufacturer U13 0 <br /> New Tanks Existing Tanks B o 2 .; t <br /> a.U in h rn L,3 r.. <br /> Septic or Holding Tank i 000 t 0 Ca'd ` �Q_ t _ <br /> Dosing Chamber Cos rb l <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) tuber's Signature MP/MPRS Number Business Phone Number <br /> Steven Tesmer Z7-.7 t <br /> Plumber's Address(Street,City,State,Zip Code) �0 608-R37 5297 <br /> N8458 CM 0 Waterloo,WI 53594 <br /> VIII.County/Department Use Only <br /> ®Approved I 0 Disapproved I Permit Fee I Date Issued I tssui irent Signature <br /> r 0 Owner Given 1 vu.s,,n for Denial 1 $ 1360.00 09/24/2020 M,4".n .0/ <br /> I IX.rand tonne of pprcvarro_as___for., <br /> ----....--- - -rr.....,.,..�caavu� LisapllrOvai , i / <br /> Protect at-grade site and area 15 feet downslope in its natrual condition. *See notes on dosing <br /> No compaction, disturbance, excavation, or vehicular traffic is allowed. <br /> Attach to complete plans for the system and submit to the County only on paper not less than S i2 x It inches in size <br /> SBD-6398(R03/14) <br />