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commerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> 'sco r"'s I fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2015-00169 <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 <br /> POWTS are submitted to the Department of Commerce.Personal information you provide may be used for Project Address(if different than mailing) <br /> tm <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 /> WAYNE L ACE 0509-083-8485-0 <br /> Property Owner's Mailing Address Property Location <br /> 1219 COUNTY HIGHWAY D <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE / SW 14 Section 8 <br /> OREGON, WI 53575 (circle one) <br /> T 05 N; R 09 E <br /> 11.Type of Building(check all that apply) ` ' Lot# <br /> ICJ I or 2 Family Dwelling-Number of Bedrooms 4 ! 1 Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use <br /> City/Village/Town of <br /> 12 State Owned-Describe Use CSM Number <br /> 13797 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. ❑ New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑ Permit Transfer to List previous Permit Number and Date Issued <br /> Before Expiration New Owner 13-2015-00169-06/01/2015 <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground El At Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component <br /> ❑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 0.6 1000 1000 91.0' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o y <br /> m u ti New Tanks Existing Tanks N O y, —d 2 w p <br /> a co <br /> N� <br /> rn it0 a <br /> Septic or Holding Tank 1250 1250 1 Crest ✓ <br /> Dosing Chamber <br /> 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 1 mg Agent Signature <br /> El Approved ❑Disapproved <br /> ❑Owner given reason for denial $1,246.00 06/01/2015 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 />