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commerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> 'S CO fly 1 n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00291 <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 /> govemmental 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 4924 SCHERBEL RD <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 /> GARY L NELSON 0807-324-8135-0 <br /> Property Owner's Mailing Address Property Location <br /> 4924 SCHERBEL RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE '/ SE /4 Section 32 <br /> BLACK EARTH, WI 53515 (circle one) <br /> T 08 N; R 07 E <br /> II.Type of Building(check all that apply) Lot# <br /> El I or 2 Family Dwelling-Number of Bedrooms 3 ] Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use CityNillage/Town of <br /> ❑State Owned-Describe Use CSM Number TOWN OF BERRY <br /> 14332 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. ❑New System El 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 E1 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 /> 450 1.0 450 450 99.3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units m <br /> ti 0 o t y u <br /> New Tanks Existing Tanks y o N 2 a) a m <br /> n O d5in rn ijO a <br /> Septic or Holding Tank 1050 0 1050 1 Meade ✓ <br /> Dosing Chamber 600 0 600 0 <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 /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved Disapproved <br /> ❑Owner given reason for denial $1,246.00 09/21/2016 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Protect mound system site and area 15 feet downslope from soil compaction,soil excavation,and vehicular traffic. <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 />