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tiicommerce.wl.gov County <br /> Safety and Buildings Division Dane <br /> SCO n S'n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2015-00266 <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 Project Address(if different than mailing) <br /> state-owned POWTS are submitted to the Department of Commerce.Personal information you 4450 COUNTY HIGHWAY J <br /> nrnvirlr may he ncrri fnr cernnriary nurnocec in arrnrdan-e with thr Privacy I aw c 15 04(11(m) <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel if <br /> HARLAN OVERLAND 0707-283-9500-8 <br /> Property Owner's Mailing Address Property Location <br /> 2670 COUNTY HIGHWAY E <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE 'V4 SW ''A Section 28 <br /> MT HOREB, WI 53572 T 07 N R 07 (circle one) <br /> II.Type of Building(check all that apply) Lot# <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use City/Village/Town of <br /> ❑State Owned-Describe Use <br /> CSM Number TOWN OF CROSS PLAINS <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. `❑New System El Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explai <br /> List previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumbe ❑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 1Z1 At Grade ❑Mound>24 in.of suitable so ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component: ❑Pretreatment device: <br /> V.DispersalTfreatment Area Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf Dispersal Area Required(sf) Dispersal Area Proposed(sf System Elevation <br /> 300 .6 500 530 94.75 <br /> VI.Tank Info Capacity in Total #of Manufacturer :: <br /> Gal ons Gallons Units m ° m <br /> New Tanks Existing Tanks y c ar ? y a <br /> a O c in U) i 0 a <br /> Septic or Holding Tank 1000 1000 1 dalmaray ✓ <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 /> Scott Lovelace Permit application completed online 226852 (608)-46-3314 <br /> Plumber's Address(Street,City,State,Zip Code <br /> 9914 County Highway M, Argyle, WI 53504- <br /> VIII.Count /Department Use Only <br /> 21 Approved Iiisapproved <br /> ❑ Permit Fee Date Issued <br /> owner given reason for denial $1,246.00 08/26/2015 Issuing Agent Signature Michael Griffin <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 />