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commerce.wl.gov County <br /> Safety and Buildings Division Dane <br /> 'SCO f 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 13-2016-00232 <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 4 <br /> BMZ ENTERPRISES LLC 0808-043-7032-0 <br /> Property Owner's Mailing Address Property Location <br /> 3887 OBSERVATORY RD <br /> Govt.Lot <br /> City, State Zip Code Phone Number SE i/4 SW V, Section 4 <br /> CROSS PLAINS, WI 53528 (circle <br /> T 08 N; R 08 (ci <br /> II.Type of Building(check all that apply) Lot# <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms 12 Subdivision Name <br /> Block# SPRINGFIELD CORNERS COMMER <br /> El Public/Commercial-Describe Use Office/warehouse hi City/V illage/town of <br /> El 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. to 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 /> 269 0.5 538 900 98.5 <br /> VI.Tank Info Capacity in Total #of Manufacturer a? <br /> Gallons Gallons Units a <br /> as ti E ,9 a w <br /> New Tanks Existing Tanks ai w a <br /> mo � � m jjm � <br /> a o in(. in ii O a <br /> Septic or Holding Tank 1050 0 1050 1 Meade V <br /> Dosing Chamber 600 0 600 1 Meade ✓ <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 /> Steve Crosby Permit application completed online 227009 (608) 849-8771 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 7361 Darlin Ct, Dane, WI 53529 <br /> VIII.County/Department Use Only <br /> - <br /> Approved disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner given reason for denial $681.00 08/04/2016 Brandon Macomber <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 />