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rCe.w•gov County <br /> Safety and Buildings Division Dane <br /> i sco n s i n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2015-00074 <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(IXm),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> DAVID W IANNE 0911-303-0524-0 <br /> Property Owner's Mailing Address Property Location <br /> 3038 BUNKER VW <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE y4 SW 1/4 Section 30 <br /> SUN PRAIRIE,WI 53590 (circle one) <br /> T 09 N; R 11 E <br /> II.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms 4 64 Subdivision Name <br /> Block# BRISTOL GARDENS <br /> ❑ Public/Commercial-Describe Use <br /> 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 ❑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 98-96.5 <br /> VI.Tank Info Capacity in Total #of Manufacturer w <br /> Gallons Gallons Units L o m <br /> New Tanks Existing Tanks o c 1 2 M m <br /> o o Ul y m it L <br /> Septic or Holding Tank - 1286 1286 1 Meade ✓ <br /> Dosing Chamber 800 800 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 R Crosby Permit application completed online 227009 (608)849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 Darlin Drive,Dane,WI 53529- <br /> VIIL County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved disapproved <br /> ['Owner given reason for denial $431.00 04/06/2015 James Meyerhofer <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Shallow cells,soil must be dry for installation. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x 11 inches in size <br />