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commerce.WL.gov County Safety and Buildings Division Dane SCO ii S i fl 201 W.Washington Ave.,P.O.Box 7162 Madison,WI 53707-7162 Sanitary Permit Number(filled in by Co) Department of Commerce 13-2017-00080 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 secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. I.Application Information-Please Print All Information Property Owner's Name Parcel DAVID W SMITHBACK 0612-182-8640-0 Property Owner's Mailing Address Property Location 1469 KRABY DR Govt Lot. City,State Zip Code Phone Number NW 1/4 NW 1/4 Section 18 DEERFIELD,WI 53531 Not Provided Township: 06 N: Range: 12 E IL Type of Building(check all that apply) Lot Number Subdivision Name 1 0 I or 2 Family Dwelling-Number of Bedrooms: 2 Block Number CityNillage/Town of ❑ Public/Commercial-Describe Use: CSM Number ❑ State Owned-Describe Use: 12034 III.Type of Permit:(Check only one box on line A.Complete line B if applicable) ❑ Replacement ❑Other Modification to Existing System(explain) A. RI 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) 0 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At Grade ❑Mound>24 in.of suitable soil ❑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 300 .4 750 756 95.5,96.0 Capacity in Gallons Total ti of .0 °1 0 VI. Tank Info: Gallons Units Manufacturer a c a r a New Tanks Existing Tanks U u. in Septic/Holding Tank 1,000 0 1,000 I Crest ✓ Dosing Chamber 0 0 0 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 Robert Everson Permit application completed online 226114 (608)835-7031 Plumber's Address(Street,City,State,Zip Code) 5285 Lincoln Rd,Oregon,WI 53575- VIII.County/Department Use Only ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature 0 Approved ❑ Owner given reason for denial $ 409.00 03/30/2017 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.