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commelrce.wl.gov County <br /> Safety and Buildings Division Dane <br /> I sCO f s,rl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(tilled in by Co) <br /> Department of Corsttr.rce Madison,WI 53707-7162 13-2016-00375 <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 Xm),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> WILLIAM J LOBENSTEIN 0812-344-9045-0 <br /> Property Owner's Mailing Address Property Location <br /> 3272 DEERFIELD RD <br /> Govt.Lot <br /> State Zip Code Phone Number i t <br /> SW /e SE /� Section 34 <br /> DEERFIELD, WI 53531 (circle one) <br /> T 08 N; R 12 E <br /> II.Type of Building(check all that apply) Lot# <br /> 0 I or 2 Family Dwelling-Number of Bedrooms 4 2 Subdivision Name <br /> Block# <br /> O Public/Commercial-Describe Use City/VillageTrown of <br /> ❑State Owned-Describe Use CSM Number <br /> 10439 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> A. 0 New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 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 /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Dther Dispersal Component: ❑Pretreatment device: <br /> V.Dispersalffreatment Area Information: <br /> Design Flow(gdp) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 .4 1500 1500 100.0,102.0 <br /> VI.Tank Info Capacity in Total #of Manufacturer m 6 e <br /> Gallons Gallons Units .0 112 U a) y o <br /> New Tanks Existing Tanks y o m 2 . 2 m <br /> a 0 urn co iL 0 a_ <br /> Septic or Holding Tank 1250 0 1250 1 Crest ✓ <br /> Dosing Chamber <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 /> Robert Dvorak Permit application completed online 226109 (608) 873-8903 <br /> Plumber's Address(Street,City,State,Zip C e) <br /> 1480 Oak Opening Dr, Stoughton, WI 53589- <br /> VIII.Coun /Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> 0 Approved disapproved <br /> ❑Owner given reason for denial $409.00 12/08/2016 Joseph Boebel <br /> IX.Conditions of ApprovaVReason 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 /> 1 <br />