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commerce.wigov - County <br /> Safety and Buildings Division Dane <br /> 1 SCO 118'fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> p.tm.r of Commerce Madison,WI 53707-7162 13-2015-00347 <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 <br /> secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> CAPITOL INVESTMENTS INC 0811-123-4188-0 <br /> Property Owner's Mailing Address Property Location <br /> 13845 BULLARD RD Govt.Lot <br /> City,State Zip Code Phone Number SW / SW y4 Section 12 <br /> EVANSVILLE, WI 53536 (circle one <br /> T 08 N. R 11 E <br /> II.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms 5 18 <br /> Subdivision Name <br /> Block# SAVANNAH VALLEY <br /> ❑Public/Commercial-Describe Use <br /> City/Village/Town of <br /> 111 State Owned-Describe Use CSM Number <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 ❑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 ❑Mound?24 in.of suitable soil PJ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component: ❑Pretreatment device: <br /> V.Dispersallfreatment Area Information:_ <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 750 0.6 1250 1275 93.4' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units co E t0 w <br /> New Tanks Existing Tanks e o ,&3 Y CD . M to <br /> c O cn to N ir.(9 a <br /> Septic or Holding Tank 1650 1650 1 Meade ✓ <br /> Dosing Chamber 1000 1000 1 Meade ✓ <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 /> Steve R Crosby Permit application completed online 227009 (608) 849-8771 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 7361 Darlin Drive, Dane, WI 53529- <br /> VIII.County/Department Use Only <br /> 0 Approved disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner given reason for denial $1,246.00 10/22/2015 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <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 8 112 x 11 inches in size <br />