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tiicommerce.wl.gov County <br /> Safety and Buildings Division Dane <br /> SCOfl S'fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00015 <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 /> NICHOLAS A BORELLI 0607-234-9740-0 <br /> Property Owner's Mailing Address Property Location <br /> 10637 MIDTOWN RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE '/ SE '/, Section 23 <br /> VERONA, WI 5359 (circle one) <br /> II.Type of Building(check all that apply) / _ Lot# T 06 N; R 07 E <br /> 121 1 or 2 Family Dwelling-Number of Bedroom`' 3 Subdivision Name <br /> � Block# <br /> ❑ Public/Commercial-Describe Use <br /> CityNillage/I'own of <br /> El State Owned-Describe Use CSM Number <br /> 10595 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. 12)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 /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At Grade lZ 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 0.6 1000 1462 <br /> VI.Tank Info Capacity in Total #of Manufacturer 81 <br /> v <br /> Gallons Gallons Units jz,.°E .U m H u <br /> w U <br /> New Tanks Existing Tanks c at 2 Y a <br /> a0 U)65 Cl) ILO a <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 Co e) <br /> 7361 Darlin Drive, Dane, WI 53529- <br /> VIII.County/Department Use Only _ ----w-- <br /> Permit Fee Date Issued `Issuing Agent Signature <br /> Ef Approved cpisapproved <br /> ❑owner given reason for denial $1,246.00 02/03/2016 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 />