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nRrit Industry Services Division County <br /> .01 Dane Sanitary (tobyCo.) <br /> (-- <br /> ff,:i <br /> 1400 E Washington Ave Dane <br /> z `" P.O.Box 7162 Permit Number be filled in Co. <br /> Madison,WI 53707-7162 <br /> �,41'. 13-2021-00165 <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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. Wooded Ridge Trail <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Tony and Margaret Arts 0711-101-2112-0 <br /> Property Owner's Mailing Address Property Location <br /> 249 Cotton Grass Lane Govt.Lot <br /> City,State Zip Code Phone Number NW in, NE y., Section 10 <br /> Walworth, WI 53184 (608) 575-3882 (circlene <br /> T , N; R 11 o )) <br /> o <br /> II.Type of Building(check all that apply) Lot# <br /> ®1 or 2 Family Dwelling—Number of Bedrooms 4 2 Subdivision Name <br /> Block# Kennedy Hills <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> ®Town of Cottage Grove <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 13 New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 600 0.4 1500 . 1533 928.32' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units r I= ov^ <br /> R U (..) 44.--' ~ `� •R <br /> New Tanks Existing Tanks c ;? 1) 8 j; w <br /> a U iia . rn 'u. 0 P. <br /> Septic or Holding Tank 700/550 1250 2C Crest X <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,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 /> Jason Kmiecik �� - _____— 963965 (262) 527-0092 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W2459 County Road D, Elkhorn, WI 53121 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Sign re <br /> ®Approved ❑Disapproved <br /> ❑Owner Given Reason for Denial $ 440.00 06/28/2021 1 1 <br /> IX.Conditions of Approval/Reasons 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 /> SBD-6398(R.08/14) <br />