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corn 71e1ce.wi.gov County <br /> Safety and Buildings Division Dane <br /> ttisconsin 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Dopartivient of Corn. Madison,WI 53707-7162 13-2015-00304 <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 4721 GASTON CI R <br /> nrovide may he 11CM for cerondary nurnncec in arenrdanre with the Privacy I aw q 15040 Vml <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> KIRK W EVERSON 0711-042-8180-0 <br /> Property Owner's Mailing Address Property Location <br /> N8545 RIDGE RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE Vs NW Vs Section 4 <br /> VAN DYNE, WI 54979 (circle one) <br /> T 07 N; R 11 E <br /> II.Type of Building(check all that apply) Lot# <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> CityNillage/Town of <br /> ❑State Owned-Describe Use CSM Number TOWN OF COTTAGE GROVE <br /> 06734 <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 OthReconnectioner 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 87-0191 90606-09/18/2015 <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At Grade ❑Mound>24 in.of suitable so ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component: ' '❑Pretreatment device: <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf Dispersal Area Required(st) Dispersal Area Proposed(sf System Elevation <br /> 450 1152 <br /> VI.Tank Info Capacity in Total #of Manufacturer :? .o <br /> Gal ons Gallons Units m U ,n u zr,New Tanks Existing Tanks ` 5 in ai (/) LL 4 04 <br /> a C7 a <br /> Septic or Holding Tank 1000 1000 1 state approved ✓ <br /> Dosing Chamber <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 /> Adam Kenealy Permit application completed online 654583 (262)689-0760 <br /> Plumber's Address(Street,City,State,Zip Code <br /> 118202 Lone Road, Theresa, WI 53091 <br /> VIII.Conn /Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved disapproved <br /> ❑owner given reason for denial $257.00 09/18/2015 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Approved for re-connection to existing septic system. Rebuild house on same,existing foundation. <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 />