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commerce.wi.gov County u Safety and Buildings Division Dane sco n s n 201 W.Washington Ave.,P.O.Box 7162 Madison,WI 53707-7162 Sanitary Permit Number(filled in by Co) Department of Commerce 13-2018-00002 State Transaction Number Sanitary Permit Application In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-owned Project Address(if different than mailing) POWTS are submitted to the Department of Commerce.Personal information you provide may be used for 848 STORYTOWN RD secondary purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats. I.Application Information-Please Print All Information Property Owner's Name Parcel ERIC JAY NELSON 0509-202-8630-0 Property Owner's Mailing Address Property Location 2802 MOLAND ST Govt Lot. City,State Zip Code Phone Number NW 1/4 NW 1/4 Section 20 MADISON,WI 53704 Not Provided Township: 05 N: Range: 09 E II.Type of Building(check all that apply) Lot Number Subdivision Name El I or 2 Family Dwelling-Number of Bedrooms: 3 Block Number CityNillage/Town of ❑ Public/Commercial-Describe Use: CSM Number TOWN OF OREGON ❑ State Owned-Describe Use: 14606 HI.Type of Permit:(Check only one box on line A.Complete line B if applicable) Replacement ❑Other Modification to Existing System(explain) El A. ❑ New System System ❑ Treatment/Holding Tank Replacement Only Permit Renewal Change of Permit Transfer to List previous Permit Number and Date Issued B. ❑ Before Expiration ❑ Permit Revision ❑ Plumber ❑ New Owner - IV.Type of POWTS System/Component/Device:(check all that apply) ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At Grade ❑Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component: ❑Pretreatment device: V.Dispersal/Treatment Area Information: Design Flow(gdp) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation 450 .8 562 570 98.15 Capacity in Gallons .0 c VI. Tank Info: Total #of Manufacturer wo ° 2 en y Gallons Units c ��, rn a a New Tanks Existing Tanks U Septic/Holding Tank 1,000 0 1,000 1 Dalmaray ✓ Dosing Chamber 600 0 600 1 Dalmaray ✓ VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Plumber's Business Phone Travis Desmet Permit application completed online 1002082 (608)424-3014 Plumber's Address(Street,City,State,Zip Code) 7869 County Highway D,Belleville,WI 53508- VIII.County/Department Use Only ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature 0 Approved ❑ Owner given reason for denial $ 996.00 01/04/2018 Joseph Boebel IX.Conditions of Approval/Reason for Disapproval Approved 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.