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titcommerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> SCO 11 S;fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00056 <br /> Sanitary Permit Application - S• tate 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 P• roject 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 4 <br /> TREVER G OTTO 0507-111-8010-4 <br /> Property Owner's Mailing Address P• roperty Location <br /> 408 AZURENE LN Govt.Lot <br /> City,State Zip Code Phone Number NE ,/,t NE y, Section 11 <br /> VERONA, WI 53593 (circle one) <br /> T 05 N; R 07 E <br /> II.Type of Building(check all that apply) Lot# <br /> El I or 2 Family Dwelling-Number of Bedrooms 3 ] Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> CityNillage/rown of <br /> 13 State Owned-Describe Use CSM Number <br /> 09229 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. El 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: 0 Pretreatment device: <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf) Dispersal Area Required(se Dispersal Area Proposed(sf) System Elevation <br /> 450 0.6 750 1044 <br /> VI.Tank Info Capacity in Total #of Manufacturer o <br /> Gallons Gallons Units a.. co <br /> New Tanks Existing Tanks o 2 m ;; m 2 <br /> Q O v)v) co it O 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 /> Robert Dvorak Permit application completed online 226109 (608) 873-8903 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 1480 Oak Opening Dr, Stoughton, WI 53589- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved Disapproved <br /> Downer given reason for denial $1,246.00 03/22/2016 James Meyerhofer <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 />