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commerce.wi. il�, ; <br /> • <br /> gov Safety and Buildings tli)Is�a� ... ._..: Coutdy---.-:-., :, I. <br /> 201 W.Washington Ave.,P,fJ ox 7162 D E t% <br /> SCO11S f1 Madison,WI 53707 62 JAN 1 gal rmit N i{>Er(to be fdlcd in by Ca) <br /> Deptmdt..of Commerce <br /> Sanitary Permit Application ' 44 State T r <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,sulunission of this form to the appiopriatc iiti mental' ' 'J 3`.' 2_O Nutter <br /> -- 060 10 <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for ssWt}-otvn.�t pOWTS are Project Addrets`"(raifferent than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(lXm),Stets. TUMBLEDOWN TRAIL <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel N <br /> PREMIER BUILDERS 0708-283-1078.0 <br /> Property Owner's Mailing Address <br /> Properly Location <br /> 102 N.HOUDAY DRIVE <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE '4, SW 'A, Section 29 <br /> WAUNAKEE,WI 53597 (Cheek one) <br /> II.Type of Building(check all that apply) Lot N T 07 N; R Og p E yy <br /> El I or 2 Family Dwelling-Number of Bedrooms 4 8 Subdivision Name <br /> TUMBLEDOWN TRAILS <br /> Block N <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 0 Town of MIDDLETON <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ri New S <br /> ysttan ❑Replacement ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> System <br /> B. ❑Permit ❑Permit Revision C]Change of El Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV.Type of POWTS System/Component/Device: (Check all that apply <br /> IZI <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade U Mound>24 is of suitable soil ❑Mound<24 is 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(gpdsl) Dispersal Area Required(si) Dispersal Area Proposed(sf) System Elevation <br /> 600 0.4 1500 1512 87.0-92.0 <br /> VI,,Tank Info Capacity in Total N of Manufacturer Material • <br /> Gallons Gallons Units <br /> • Now Tanks Existing Tanks <br /> Septic or Holding Tank 1286 <br /> 1286 1 MEADE Prefab Concrete <br /> Dosing 800 800 1 MEADE <br /> VII.Responsibility Statement-I,the undersigned,assume -',s fellation of the POWTS shown on the attached plans.i.t Plumber's Name(Print) Plumber's: t �' MP/MPRS Number Business Phone Number <br /> STEVEN R.CROSBY //�ri' I 227009 1 808449.8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARUN DR. DANE WI 53529 <br /> VIII.County/Department Use Only <br /> Approved _Disapproved Permit Fee Dale Issued Issuing A re <br /> _Owner Given Reason for Denial S ?/ II/ f.„,,$._/ S <br /> IX.Conditions of Approval/Reasons for Disapproval 7 <br /> • Attach to complete plans for the system and submit to the County only on paper not less than S ra x I1 inches in size <br /> ‘ 9' 2(d <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />