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commerce.wi.gov Safety and Buildings Division County �n <br /> 201 W.Washington Ave.,P.O.Box 7162 DANE 1 I\G <br /> isco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce . ZU/(ll _- O O 3 6 3 <br /> ... t 1 <br /> Sanitary Permit Application tate Transaction Number <br /> in accordance with s.Comm.8121(2),Wis.Adm.Code,sup on thi fo��,,A�o t{ a�F opgtilte g vemknental <br /> unit is required prior to obtaining a sanitary permit. lot : p,1_atio lorttts fd-sttt(e-o.ned bvtlIS are Project Address(if different than mailing address) - <br /> submitted to the Department of Commerce. Personal info�kion you provide may'6e useTi se ndary <br /> purposes in accordance with the Privacy Law,s.15.04(IXrr}),'3 at9. It <br /> rr y WELCOME DRIVE <br /> I. Application Information-Please Print All Inf r 1 Linn S+EP 2 4 2014 <br /> Property Owner's Name i f SEP Parcel# <br /> SACHSE LIVING TRUST 0708-301-6821-0 ocatio <br /> Property Owner's Mailing Address - -_ Property Location <br /> 9906 TALONS WAY Govt.Lot <br /> City,State Zip Cgs Phone Number SE 'A, NE '/., Section 30 <br /> VERONA, WISg3 (Check One) <br /> T 07 N; R 08 al E W <br /> H.Type of Building(check all that apply Lot it ❑ <br /> 121 or 2 Family Dwelling--Number of Bedroo s 6 21 Subdivision Name <br /> CHERRYWOOD FOREST <br /> Block a <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> State Owned-Describe Use CSM Number ❑Village of <br /> 0 Town of MIDDLETON <br /> Iii.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System ❑Replacement ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> System <br /> B. ❑Permit n Permit Revision 1:1 Change of d Permit Transfer to List Previous Permit Number and Date issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV.Type of POWTS System/Component/Device: (Check all that apply)._ <br /> t <br /> Non-Pressurized In-Ground ❑Pressurized in-Ground ❑At-Grade lJ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) El Pretreatment Device(explain) <br /> V.DispersalfTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 900 0.4 2260 2288 4%,0 88.0,89.0,90.0,91.0,92.0 <br /> VI.Tank Info Capacity in Total it of Manufacturer ' Material <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank 2000 2000 1 MEADE Prefab Concrete <br /> Dosing Chamber 1300 1300 1 WADED Prefab Concrete <br /> VII.Responsibility Statement- I,the undersigned,assume- ponsibl .for•1 stall n of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu bet's Sign j`) MP/MPRS Number Business Phone Number <br /> STEVEN R.CROSBY i� -- 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) --." <br /> 7361 DARLIN DR. DANE WI 53529 - <br /> Vi .County/Department Use Only <br /> (Approved — Disapproved Permit Fee •ate Issued Issuin• :ent ig - e <br /> �`- Owner Given Reason for Denial $ ' ilk <br /> iX,Conditions of Approval/Reasons for Disapproval <br /> A e.,e O -e- v-e-A-Lk o---■ CC - d/10- ■ / 7-6:244-- <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 r/2 x I I inches in size <br /> t1 ( 2 ,{ <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />