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commerce.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 /> a Corsros Madison,WI 53707-7162 13-2014-00353 <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(lxm),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> DANIEL P SEARS SR 0510-081-9100-0 <br /> Property Owner's Mailing Address Property Location <br /> 372 MEDINAH ST <br /> Govt.Lot <br /> City,State Zip Code Phone Number SW '/4 NE 1/4 Section 8 <br /> OREGON,WI 53575 (circle one)T 05 N; R 10 E <br /> II.Type of Building(check all that apply) -� Lodi <br /> 0 I or 2 Family Dwelling-Number of Bedrooms <br /> 3 1 Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use <br /> City/Village/Town of <br /> CSM Number Town of Rutland <br /> ❑ State Owned-Describe Use <br /> 11985 <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 ❑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 /> O Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component: ❑Pretreatment device: <br /> V.DispersaVCreatment Area Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.4 1125 1128 95.7',93.9'. <br /> VI.Tank Info Capacity in Total #of Manufacturer t, <br /> Gallons Gallons Units a P U m O <br /> New Tanks Existing Tanks g c d 1 Y a A a <br /> a O co u) (/) u 0 d <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 /> Robert Everson Permit application completed online 226114 (608)-83-7031 <br /> Plumbers Address(Street,City,State,Zip Code) <br /> 5285 Lincoln Rd,Oregon,WI 53575- <br /> VIIL County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> O Approved ❑Disapproved <br /> ❑Owner given reason for denial $431.00 10/16/2014 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <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 />