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i. commerce.wi.gov 'erO fl S' County Safety and Buildings Division Dane 201 W.Washington Ave.,P.O.Box 7162 Madison,WI 53707-7162 Sanitary Permit Number(filled in by Co) Department of Commerce 13-2020-00446 State Transaction Number Sanitary Permit Application In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-owned Project Address(if different than mailing) . POWTS are submitted to the Department of Commerce.Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. I.Application Information-Please Print All Information Property Owner's Name Parcel THOMAS FOX RUTHERFORD 0907-032-8580-0 Property Owner's Mailing Address Property Location 1824 VILAS AVE Govt Lot. City,State Zip Code Phone Number NW 1/4 NW 1/4 Section 3 MADISON,WI 53711 Not Provided Township: 09 N: Range: 07 E II.Type of Building(check all that apply) Lot Number Subdivision Name 4 El 1 or 2 Family Dwelling-Number of Bedrooms: 5 Block Number CityNillage/Town of ❑ Public/Commercial-Describe Use: CSM Number ❑ State Owned-Describe Use: 14772 III.Type of Permit:(Check only one box on line A.Complete line B if applicable) ❑ Replacement 0 Other Modification to Existing System(explain) A. Il New System System 0 Treatment/Holding Tank Replacement Only Permit Renewal Change of Permit Transfer to List previous Permit Number and Date Issued B. 0 Before Expiration ❑ Permit Revision ❑ Plumber ❑ New Owner - IV.Type of POWTS System/Component/Device:(check all that apply) ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil 0 Holding Tank 0 Other Dispersal Component: 0 Pretreatment device: V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation 750 .6 1,250 1,250 104.5 2 y Capacity in Gallons Total #of E o 8 u`) VI. Tank Info: Gallons Units Manufacturer a o D a New Tanks Existing Tanks U V. Septic/Holding Tank 1,600 0 1,600 1 Wieser ✓ Dosing Chamber 1,000 0 1,000 1 Wieser ✓ VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Plumber's Business Phone David Schmitt Permit application completed online 999773 (608)643-8531 Plumber's Address(Street,City,State,Zip Code) Po Box 486,402 John Q Adams, Sauk City,WI 53583 VIII.County/Department Use Only ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature El Approved ❑ Owner given reason for denial $ 1,360.00 12/30/2020 Joseph Boebel IX.Conditions of Approval/Reason for Disapproval Approved 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.