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commerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> ti <br /> ero n S I fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00060 <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 /> WILLIAM SCHMITT 0708-324-4045-0 <br /> Property Owner's Mailing Address Property Location <br /> 1801 SHADY POINT DR Govt.Lot <br /> City,State Zip Code Phone Number SW '/4 SE '/4 Section 32 <br /> VERONA, WI 53593 (circle one) <br /> T 07 N; R 08 E <br /> II.Type of Building(check all that apply) Lot# <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 5 _ 5 Subdivision Name <br /> Block# MEADOW ROAD ESTATES <br /> ❑ Public/Commercial-Describe Use City/Village/Town of <br /> ❑ 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 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 /> 750 0.6 1250 1332 <br /> VI.Tank Info Capacity in Total #of Manufacturer 2i <br /> Gallons Gallons Units a 2 t j 4 w u <br /> al 1:5 New Tanks Existing Tanks m o ) 2 D m m <br /> aU coi <br />