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commerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> I SCd ri 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 13-2016-00143 <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 /> govemmental 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 /> BIL/GAV PROPERTIES LLC 0811-323-9550-0 <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE 1/4 SW 1/4 Section 32 <br /> SUN PRAIRIE, WI 53590 (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 1 Subdivision Name <br /> Block# <br /> Public/Commercial-Describe Use Office <br /> CityNillage/Town of <br /> ID State Owned-Describe Use CSM Number <br /> 09968 <br /> III.Type of Permit: (Check only one box on line A.Complete line B if applicable) <br /> A. 121 New System 0 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 ❑ 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 /> 192 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks c w a m m <br /> a U in in U) ii(7 a <br /> Septic or Holding Tank 2000 2000 1 Crest ✓ <br /> Dosing Chamber <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 JJisapproved <br /> ❑Owner given reason for denial $409.00 06/02/2016 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <br /> To properly anchor tank against force of buoyancy,you must provide 20 inches of soil cover over the tank,or,use 4.3 yards of concrete anchor on <br /> top of tank. <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 />