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( <br /> `� - `.%t(bpialIrr'(1 CNlrh l0-3-7e,zz <br /> .:W.'r`!'-t, Industry Services Division County <br /> ,,,..:W.' <br /> e N,`• 4822 Madison Yards Way DANE <br /> pa ` =p • ';' Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> \ <br /> S 1. • P:O.Box 7162 <br /> '--'''---4' Madison,WI 53707-7162 <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 arc 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. <br /> I.Application Information-Please Print All Information TOWN HALL RD <br /> Property Owner's Name Parcel# <br /> SAMANTHA&JUSTIN BEREZOWITZ 0607-083-8440-0 <br /> Property Owner's Mailing Address Property Location <br /> 9520 DREGERS WAY Govt.Lot <br /> City,State Zip Code Phone Number <br /> VERONA,WI 53593 NE �,. SW y, Section 8 . <br /> II.Type of Building(check all that apply) Lotk T 6 NR 7 E aril+ , <br /> La 1 or 2 Family Dwelling-Number ofBcdroonss 4 3 Subdivision Name . <br /> Block N <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> I'Town of SPRINGDALE <br /> 15133 <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. fJ New System ❑Replacement System ❑Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B' El Holding Tank ❑ In-Ground ❑At-Grade l Mound ❑ Individual Site Design ❑Other Type(explain) <br /> (conventional) 7 Zy-"Sit:tit '- Sc i <br /> C. ❑Renewal Before ❑Revision 11 Change of Plumber ❑Transfer to New Owner <br /> List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) ' Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 600 0.61 ,,cell 1000 /(,,cc. 1657.'5/ 6',.?Z _ 115.75' <br /> Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units c u <br /> Tank Information ° U <br /> New Tanks Existing Tanks '` " c -o n m <br /> 4.U in 2 vt i+.0 0,• <br /> Septic or Holding Tank 1286 --- 1286 1 MEADS X <br /> Dosing Chamber 650 --- 650 1 MEADE X <br /> V.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 W. MEINHOLZ .__?.. MPRS 220165 (608) 831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DR. STE. 1, DANE, WI 53529 <br /> VI.County/Department Use Only id I1 big - GL 10- 3-- 74,i Z <br /> Approved ❑Disapproved <br /> Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial /13100 /0-5--7 Z 4/1l.�r`-e-; Q ' <br /> Conditions of Approval/Rcasons for Disapproval <br /> Protect & Maintai6,YMounf ❑ At-Grade site and 15 feet downslope in its natural <br /> condition. No compaction, excavation, disturbance, or vehicular traffic allowed. <br /> *Ensure tank locations are within 150' horizontally&within 15'vertical depth difference to all-weather service pad.', <br /> _Specific servicing mechanics must be provided to PHMDC in writing(completed by owner& pumper) if exceeded.* <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x I I inches in size <br /> SBD-6398(R.03/21) <br />