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commerce.wl.gov County <br /> Safety and Buildings Division Dane <br /> f SCO f l S f fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department oT Commerce Madison,WI 53707-7162 13-2016-00262 <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(1)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> FJD FARM LLC 0712-211-7626-0 <br /> Property Owner's Mailing Address Property Location <br /> 105 HOLMAN RD Govt.Lot <br /> City,State Zip Code Phone Number SE i/, NE t/, Section 21 <br /> DEERFIELD, WI 53531 (circle one) <br /> T 07 N. R 12 E <br /> II.Type of Building(check all that apply) Lot# <br /> Q 1 or 2 Family Dwelling-Number of Bedrooms 5 1 Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use CityNillage/Town of <br /> ❑State Owned-Describe Use CSM Number <br /> 13201 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. Q New System ❑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 ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ['Other Dispersal Component: ['Pretreatment device: <br /> V.DispersallTreatment Area Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 750 0.5 1500 1500 95.1',95.5',95.9',96.3',96.7'. <br /> VI.Tank Info Capacity in Total #of Manufacturer 11? c <br /> Gallons Gallons Units . o ,, o <br /> New Tanks Existing Tanks E c p> 2 d a m 2 <br /> aU coy) to 1i0 a <br /> Septic or Holding Tank 1600 1600 1 Crest ✓ <br /> Dosing Chamber 800 800 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 /> Travis Desmet Permit application completed online 1002082 (608)424-3014 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 7869 County Highway D, Belleville, WI 53508- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Q Approved ❑Disapproved <br /> ['Owner given reason for denial $431.00 08/31/2016 Richard Herro <br /> IX.Conditions of Approval/Reason for Disapproval <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 />