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COtT merce.wi.goV County <br /> Safety and Buildings Division Dane <br /> 'Sco f s,fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department of Commerce Madison,WI 53707-71Department 13-2016-00196 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submitsion 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 2276 GLEN OAKS CIR <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 /> BRET CLOSTERMERY 0811-343-0523-0 <br /> Property Owner's Mailing Address Property Location <br /> 289 VALLEY RIDGE DR <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE �1/4 4 SW ��4 Section 34 <br /> SUN PRAIRIE, WI 5359° (circle one) <br /> T 08 N; R 11 E <br /> II.Type of Building(check all that apply) / st# <br /> � <br /> Q / <br /> . �1 or 2 Family Dwelling-Number of B- oms 5' 3 Subdivision Name <br /> Block# OAKS,THE <br /> ❑Public/Commercial-Describe Use <br /> CityNillage/Town of <br /> ❑State Owned-Describe Use CSM Number TOWN OF SUN PRAIRIE <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 ❑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 /> O 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 /> 750 0.4 1875 1900 95.6' <br /> VI.Tank Info Capacity in Total #of Manufacturer m <br /> Gallons Gallons Units .o ' O 0 o <br /> New Tanks Existing Tanks o ` aa) S m 2 <br /> acs in to' u) ii o a <br /> Septic or Holding Tank 1650 1650 1 Meade ✓ <br /> Dosing Chamber 1000 1000 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 /> Plumbers Address(Street,City,State,Zip Co e) <br /> 7361 Darlin Drive, Dane, WI 53529- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved pisapproved <br /> ❑Owner given reason for denial $431.00 07/12/2016 Richard Herro <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 />