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commerce.wi.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 /> Department of Commerce Madison,WI 53707-7162 13-2015-00202 <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(1)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel s <br /> WILLIAM G THORSON 0509-363-9980-0 <br /> Property Owner's Mailing Address Property Location <br /> 7301 ARTIC FOX DR <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE / SW v, Section 36 <br /> MADISON, WI 53719 (circle one) <br /> T 05 N; R 09 E <br /> II.Type of Building(check all that apply) Lot# <br /> 0 I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use <br /> City/Village/Town of <br /> 1:1 State Owned-Describe Use CSM Number <br /> 10481 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. El New System El Replacement System •❑ Treatment/Holding Tank Replacement Only 0 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 /> 10 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank DOther 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 /> 450 0.7 643 650 100.0' <br /> VI.Tank Info Capacity in Total h of Manufacturer y <br /> Gallons Gallons Units a P o y <br /> New Tanks Existing Tanks g o 2 i , to 2 <br /> a U in rn co it 0 a <br /> Septic or Holding Tank 1000 1000 1 Dalmaray V <br /> . <br /> Dosing Chamber 600 600 1 Dalmaray ✓ <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 /> Timothy Jelle Permit application completed online 227525 (608)845-7466 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1330 Fritz Road,Verona, WI 53593- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued uing Agent Signature <br /> El Approved ❑Disapproved <br /> ❑Owner given reason for denial $431.00 06/18/2015 Richard Herro <br /> IX.Conditions of Approval/Reason 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 />