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commerce.wl.gov County <br /> Safety and Buildings Division Dane <br /> SCOn s i n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department d Commerce Madison,WI 53707-7162 13-2015-00336 <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 state-owned Project Address(if different than mailing) <br /> POWTS are submitted to the Department of Commerce.Personal information you provide may be used for 1915 N KOLLATH RD <br /> secondary purposes in accordance with the Privacy Law,s.15.04(lxm),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> GEORGE VADYAK III 0607-264-9330-9 <br /> Property Owner's Mailing Address Property Location <br /> 80 ATLANTIC AVE <br /> Govt.Lot <br /> City,State Zip Code ' one Number SW i/4 SE i/4 Section 26 <br /> WEST SAYVILLE,NY 11 � (circle one) <br /> T 06 N; R 07 E <br /> II.Type of Building(check all that apply Lot <br /> 0 1 or 2 Family Dwelling-Number of Be'.som 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> CityNillage/Town of <br /> ❑State Owned-Describe Use CSM Number TOWN OF SPRINGDALE <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. 0 New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> List previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑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 ❑At Grade 0 Mound>24 in.of suitable soil ❑ 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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.6 750 1482 96.5' <br /> VI.Tank Info Capacity in Total #of Manufacturer a3 <br /> Gallons Gallons Units a V d.) <br /> New Tanks Existing Tanks m e :; 2 „�� a m m <br /> a O <n in rn IL 0 a <br /> Septic or Holding Tank 1000 1000 1 Crest ✓ <br /> Dosing Chamber 600 600 1 Crest ✓ <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 /> Travis Desmet Permit application completed online 1002082 (608)424-3014 <br /> Plumber's Address(Street,City,State,Zip C e) <br /> 7869 County Highway D, Belleville, WI 53508- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved Disapproved <br /> ❑Owner given reason for denial $1,246.00 10/16/2015 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <br /> See Plan Change: Mound is 30'x 75'. <br /> Protect mound system site and area 15 feet downslope from soil compaction,soil excavation,and vehicular traffic. <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 />