Laserfiche WebLink
aommerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> isco n s i n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2015-00396 <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(I)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel 4 <br /> ANNE L APLIN 0712-112-9270-0 <br /> Property Owner's Mailing Address Property Location <br /> 4355 KRUEGER RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number SW 'A NW i/4 Section II <br /> MARSHALL, WI 53559 (circle one) <br /> T 07 N; R 12 E <br /> II.Type of Building(check all that apply) Lot# <br /> EI I or 2 Family Dwelling-Number of Bedrooms 4 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> CityNillage/Town of <br /> ❑State Owned-Describe Use CSM Number <br /> 14140 <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 /> 0 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.Dispersal/Treatment Area Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 0.4 1500 1512 95.0' <br /> VI.Tank Info Capacity in Total 4 of Manufacturer a <br /> Gallons Gallons Units .o � U y u <br /> New Tanks Existing Tanks c ar 2 y .n m m <br /> a O in in it 5 a. <br /> Septic or Holding Tank 1250 1250 1 Crest ✓ <br /> Dosing Chamber 750 750 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 /> Plumber's Address(Street,City,State,Zip Co e) <br /> 5285 Lincoln Rd, Oregon, WI 53575- <br /> VIII.County/Department Use Only <br /> -Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner given reason for denial $431.00 12/22/2015 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 />