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commerce.wigov 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 13-2015-00283 <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 1487 RANGE TRL <br /> nrnvide may he aced for cernndary numncec in accordance with the Privacy I aw c 15 04(11(m) <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> THOMAS A SARBACKER 0508-034-8503-0 <br /> Property Owner's Mailing Address Property Location <br /> 1487 RANGE TRL <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW '/ SE V., Section 3 <br /> VERONA, WI 53593 (circle one) <br /> T 05 N; R 08 E <br /> II.Type of Building(check all that apply) (--:.---\ Lot# <br /> El I or 2 Family Dwelling-Number of Bedroortk 3 Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use CityNillage/Town of <br /> ❑State Owned-Describe Use <br /> CSM Number TOWN OF MONTROSE <br /> Ill.Type of Permit:(Check only one box on line A.Co plete line B if applicable) <br /> A. ❑New System ❑Replacement System ❑Treat ent/Holding Tank Replacement Only a Other onnection Modification to Existing System(explai <br /> Rec , <br /> List previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Chang-of Plumbe ❑Permit Transfer to <br /> Before Expiration New Owner 93-0789-09/04/2015 <br /> IV.Type of POWTS System/Component/Device:(chec all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ Grade ❑Mound>24 in.of suitable so ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank :Other Dispersal Component: ❑Pretreatment device: <br /> V.Dispersal/Creatment Area Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf Dispersal Area Required(sf) Dispersal Area Proposed(sf System Elevation <br /> 450 0.5 "00 900 94.3 <br /> VI.Tank Info Capacity in Total #of Manufacturer al . <br /> Gallons Gallons_ Units a m o at pn <br /> New Tanks Existing Tanks m o ;; aa) a m Ii <br /> 'd <br /> 0 in rn to LE C.5 a <br /> Septic or Holding Tank 1 000 1000 1 Crest ✓ <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1.the undersigned.assum:responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa re MP/MPRS Number Business Phone Number <br /> Timothy Jelle Permit appli ation completed online 227525 '(608) 845-7466 <br /> Plumber's Address(Street,City,State,Zip Code <br /> 1330 Fritz Road, Verona, WI 53593- <br /> VIII.Count /Department <br /> Permit Fe. <br /> /Department Use Only <br /> tre <br /> 11 Approved Disapproved <br /> wner given reason for denial $tit F il0 Date Issued Issuing Agent Sigiiatg 09/04/2015 j Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Reconnection to existing POWTS installed/inspected/appr.ved 12-21-1993. �— - <br /> Attach to complete plans for the system an. submit to the County only on paper not less than 8 1/2 x 11 inches in size <br />