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COmmerce.wl.gov County <br /> Safety and Buildings Division Dane <br /> t nee 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co)son,WI 53707-7162 <br /> Department of <br /> Madison, 13-2016-00222 <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(1Xm),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> LAWRENCE R GRAB 0907-011-8051-8 <br /> Property Owner's Mailing Address Property Location <br /> 1501 BRYNWOOD DR <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE y, NE v, Section 1 <br /> MADISON, WI 53716 (circle one <br /> T 09 N; R 07 E <br /> II.Type of Building(check all that apply) Lot# <br /> I1 1 or 2 Family Dwelling-Number of Bedrooms 4 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> CityNillage/Town of <br /> El State Owned-Describe Use CSM Number <br /> 08524 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. a New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to List previous Permit Number and Date Issued <br /> Before Expiration New Owner - <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> El 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 1500 96.0;94.9;93.7 <br /> VI.Tank Info Capacity in Total #of Manufacturer d - - <br /> Gallons Gallons Units . m c d U <br /> New Tanks Existing Tanks a)5 aUi 2 w aim .N eo <br /> it U rn U) co u.3 d <br /> Septic or Holding Tank 1250 0 1250 1 Crest ✓ <br /> Dosing Chamber 750 0 750 1 Crest ✓ <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 /> Ken Haugen Permit application completed online 224121 (608)205-0238 <br /> Plumber's Address(Street,City,State,Zip Co e) - <br /> 317 W Broadway St, Stoughton, WI 53589- <br /> VIII.County/Department Use Only <br /> Approved disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ['Owner given reason for denial $431.00 08/03/2016 Brandon Macomber <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Rissy dose is not to exceed 120 gal/dose. Adjust Rissy dose from 123 gal/dose to<120 gal/dose by displacement or shimming. <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 />