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Warn•` County a <br /> ✓.�ur�►� vJ/ <br /> Safety and Buildings Division Dane s <br /> 'u e,*SA 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co:) <br /> o rs p jt i Madison,WI 53707-7162 <br /> ��a<='fir <br /> 13- or ? 0te03 <br /> Sanitary Permit Application StWcTmnsactionNumber <br /> to accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety nod Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information-Please Print AU Information <br /> Property Owner's Name Parcel <br /> ''Brian Miller 0608-331-9940-7 <br /> Property Owner's Mailing Address Property Locution. <br /> 1815 Locust Drive Govt,Lot_ <br /> City,State Zip Code Phone Number EA, NE'l L,:Section 33 <br /> Verona,WI 53593 575-5976 (circle one) <br /> 11.Type of Building(check all that apply) Lot y T 6 N; R 8 E w 1V <br /> ®I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block* . <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 1/ 2604 ®Town of Verona <br /> Ili.Type of Permit: (Check o gone box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑TreatmentAiolding Tank <br /> Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer toNew <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ®Monad>24 in.ofsuiteblesoil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank '0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Appli on Rate(gpdsl) Dispersal Area Requirreed Dispersal Area (s System Elevation <br /> 450 (c rj.5 i55 ? 100.1', 100.9' <br /> VI.Tank Info - Capacity.in Total g of M facturer <br /> Gallons • Gallons Units o v <br /> New Tanks Existing Tanks u 8 " E :2:0 <br /> u y3 rn EO <br /> Septic or Balding Tank 1000 1000 1 Crest x <br /> Dosing Chamber 600 600 .1 Crest x <br /> VII.Responsibility Statement 1,the undersigned,assume responsibUlty for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum s Signature MP/MPRS Number Business Phone Number <br /> tie r.CL is D Sv►1d' `, - lcx/zor- ag'30�� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 'v7g � Cft aid U t`' 11ea/40 cam.. s S <br /> [Il.County/Department Use Only <br /> pproved ❑Di ved Permit Fee Date Issued Issuing 11, t S'rgnatu <br /> sappro S .a �. <br /> ❑Owner Given Reason for Decrial •I*"-IN.• p/ 43 / <br /> 1X Conditions of Approval/Rensons for Dl�ppr tai " <br /> Cam , s.+ '' L s►- <br /> Attach to complete plans for the system Dail submit to the County only on paper not less than It I¢s I I inches In size <br /> SBD-6398(R 11/1 I) RECEIVED <br /> • JUN 20 2017 <br /> Public Health MDC <br /> Environmental Health <br />