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commerce.wl.gov County <br /> Safety and Buildings Division Dane <br /> tfisconsin 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Deportment of Commerce Madison,WI 53707-7162 13-2015-00036 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate <br /> governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-owned Project Address(if different than mailing) <br /> POWTS are submitted to the Department of Commerce.Personal information you provide may be used for <br /> secondary purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> JASON A HUGHES 0608-173-9701-0 <br /> Property Owner's Mailing Address Property Location <br /> 407 E VERONA AVE Govt.Lot <br /> City,State Zip Code Phone Number SE / SW y, section 17 <br /> VERONA, WI 53593 (circle one) <br /> T 06 N; R 08 E <br /> II.Type of Building(check all that apply) L• od <br /> • I or 2 Family Dwelling-Number of Bedrooms 1 ] Subdivision Name <br /> B• lockN <br /> ❑ Public/Commercial-Describe Use City/Village/Town of <br /> ❑ State Owned-Describe Use C• SM Number <br /> 09430 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. 0 New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑ Permit Transfer to <br /> Before Expiration New Owner - <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At Grade El Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component: ❑Pretreatment device: <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 0.5 1200 1470 95.0'. <br /> VI.Tank Info Capacity in Total #of Manufacturer d <br /> Gallons Gallons Units , 82 o o o <br /> New Tanks Existing Tanks y 2 Y n 2 <br /> a U m to to t;= O a <br /> • <br /> Septic or Holding Tank 1250 1250 1 Crest ✓ <br /> Dosing Chamber 750 750 1 Crest ✓ <br /> VII.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 /> Travis Desmet Permit application completed online 1002082 (608)424-3014 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7869 County Highway D, Belleville, WI 53508- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> El Approved ODisapproved <br /> ❑owner given reason for denial $1,246.00 02/20/2015 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Protect mound system site and area 15 feet downslope from soil compaction,soil excavation,and vehicular traffic. <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 />