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commerce.wi.gov County <br /> Safety and Buildings Division Dane <br /> i sco n s; n 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,WI 53707-7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce 13-2017-00008 <br /> State Transaction Number <br /> Sanitary Permit Application <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 /> BENJAMIN GEISSAL 0607-274-8470-0 <br /> Property Owner's Mailing Address Property Location <br /> 2816 SYLVAN AVE Govt Lot. <br /> City,State Zip Code Phone Number NE 1/4 SE 1/4 Section 27 <br /> MADISON,WI 53705 Not Provided Township: 06 N: Range: 07 E <br /> II.Type of Building(check all that apply) Lot Number Subdivision Name <br /> 3 <br /> El 1 or 2 Family Dwelling-Number of Bedrooms: '3 <br /> Block Number CityNillage/Town of <br /> ❑ Public/Commercial-Describe Use: <br /> CSM Number <br /> ❑ State Owned-Describe Use: 09748 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> ❑ Replacement El Other Modification to Existing System(explain) <br /> A. 0 New System System ❑ Treatment/Holding Tank Replacement Only <br /> Permit Renewal Change of Permit Transfer to List previous Permit Number and Date Issued <br /> B. ❑ Before Expiration ❑ Permit Revision ❑ Plumber El New Owner - <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground El 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(st) System Elevation <br /> 450 .6 750 750 104.5 <br /> ' <br /> Capacity in Gallons Total #of ' ti o 8 :o ii <br /> VI. Tank Info: Manufacturer ° c t.) b <br /> Gallons Units a o .) a, <br /> New Tanks Existing Tanks U is. <br /> Septic/Holding Tank 1,000 0 1,000 1 Dalmaray ✓ <br /> Dosing Chamber 600 0 600 1 Dalmaray ✓ <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 Plumber's Business Phone <br /> Scott Lovelace Permit application completed online 226852 (608)465-3314 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9914 County Highway M,Argyle,WI 53504- <br /> VIII.County/Department Use Only <br /> ❑ Disapproved Permit Fee Date Issued I Issuing Agent Signature v <br /> 177 <br /> 0 Approved <br /> 0 Owner given reason for denial $ 1,246.00 01/27/2017, Boebel <br /> IX.Conditions of Approval/Reason for Disapproval i <br /> Approved —. <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 />