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I RECEIVED uBtE: y i ,I Industry Services Division AUG 2 2015 County DANE I j.,\ = I 1400 E.Washington Ave.,PP..O Plittlic MOD MDC I Sanitary Permit Number(to be filled in by Co.) t`��t Madison,WI 03707E y nmental Health „ _./f' l r -r Sanitary Permit Application I State Transaction Number In accordance with SPS 33321(2),Wis.Adm.Code,submission of this form to the appropriate governmental sea Iis required prior to obtaining a sanitary permit.Note:Application forms for stai:owned POWTS are submitted to the Department of Safety and Professional Servies. Personal information you p-o.ide may be used for secondary Project Address(if different than mailing address) purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. I I. Application Information—Please Print All Information CTH PB Property Owner's Name - Parcel k I TREVOR&SARAH BERCEAU !0608-262-9571-0 IProperty Owner's Mailing Address Property Location 2813 MAPLE GROVE DR. SE A NW '/, Section 26 ICity, State, Zip Code I P umber MADISON,WI 53719 T 6 N,R 8 E IL Type of Building(check all that apply) l!Lot a 2 •Subdivision Name CTI or 2 Family Dwelling-Number of Bedrooms 3 Block S I❑Public'Commercial-Describe Use I CSM Number I❑City of : I❑State Owned-Describe Use 12360 ❑Village of 1 I g/l`own of VERONA !III.Type of Permit: (Check only one box on line A. Complete line B if applicable) 'A- 1 al- ;w System I 0 Replacement System i 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) I I B. I❑Permit Renewal ❑Permit Revision I 0 Change of Plumber I ❑Permit Transfer to List Previous Permit Number and Date Issued i 1 Before Expiration I New Owner IV.Type of POWTS System/Component/Device: (Check all that apply) I Cd NOn-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain): V.DispersaUTreatment Area Information: I Design Flow(gpd) I Design Soil Application Rate(gpdst) 'Dispersal Area Required(sf) I Dispersal Area Proposed(st) 1 System Elevation 450 I 0.6 750 1 EZ FLOW EQUIV. 850 1 96.5',96.6',96.8',96.8',96.8' I VI.Tank Info I Capacity in Total I 4 of Manufacturer Gallons Gallons Units _ I v j New Tanks Existing Tanks o U I .. 21 L; Septic or Holding Tank i 1000 I 1000 1 DALMARAY X I I I Dosing Chamber 1 600 600 1 DALMARAY XI- I I I �VII.Responsibility Statement-I,the undersign sume r ponsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) umb 's Si� I MPIMPRS Number Business Phone Number :SCOTT LOVELACE .r�tt �c-�L---}— 226-852 I (608)465-3314 Plumber's Address(Street,City,State? 1 Code) LOVELACE PUMP COMPANY,INC.,9914 COUNTY M,ARGYLE,WI 53504 I VIII.County/Department Use Only I Approved' ❑Disapproved Permit,ee yi�.! !Date Issued I Issuing Ag-' gnat e 5 ❑Owner Given Reason for Denial 1$ =f 4,,,.' VVV � 4,,,.'; I�� 1 IX.Conditions of Approval/Reasons for Disapproval . Attach to complete plans for the system and submit to the Cbunty only on paper not less than 8 12 x I I inches in size SBD-6398(R.08/14) al' I I I