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l <br /> ..,..4114$1-1., County !C 17 <br /> 40';.6, b. Safety and Buildings Division Dane <br /> / ,;_'; IT 201 W.Washington Ave.,P.O.Box 7162 Sanitary Pamir Number(to be Riled in by Co.) <br /> !.0 ;� <br /> C $cell' <br /> ' 'i•,,-11'."-;, r'1 Madison,WI 53707-7162 <br /> "', "r / ? -ao)(, — 003,6r <br /> Sanitary Permit Application Stoic Transaction Number <br /> la accordance with SPS 383.21(2).Wis.Anima.Code.submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Nalt:Application forms for state-owned POWTS are submitted to Project Address(if dilTerem than mailing address) <br /> the Dcpanment of Safety and Professional San ks. Personal infomtallon you provide may be used for secondary <br /> purposes in accordance with the Privacy Lase,s.15.04(1)(m),Stan. Juedes Lane <br /> I. Application information-Please Print All Information <br /> Propaly Owner's Name RE CE j'j . ` Parcel 8 <br /> William&Anne Lobenstein t io' r n 0812-344-9045-0 <br /> Property Owner's Mailing Address DEC 08 20S Property Locution <br /> 3272 Deerfield Road a, Govt.Lot <br /> City,State Zip Code Err inn,lo. SW ;s, SE iii.section 34 <br /> Deerfield,WI 53531 1''/ealtn (circle one) <br /> II.Type of Building(check all that apply) Lot p T 8 Ni R 12 E a 1V <br /> 0 I or 2 Family Dwelling-Number of Bedrooms 4 2 Subdivision Naar <br /> Block X <br /> ❑Publlc/Commercial-Describe Use <br /> ❑Chyof • <br /> CI sate Owned-Describe Use CSM Number ❑Village of <br /> 10439 ®Town or Medina <br /> • <br /> lir.Type of Permit'. (Cheek only one box on line A. Complete line B If applicable) <br /> A' M New System ❑Replacement System ❑Trattnmt/HokGngThok AeplacrnteM Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumi er ❑Permit Trmtskr to New <br /> List Previous Permit Number and NM Issued <br /> Before Etpiratioo Owner <br /> IV.Type of POWTS System/Component/Device:*-(Check all that apply) <br /> 51 Non-Pressurized In-Ground ❑Pressurised In-Ground ❑Al-Grade ❑Monad>>14 in.of suitable soil ❑Mound<34 in.of suitable soil <br /> ❑ItoWing Tod ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DlspersaVTreatm_ eut Area Information: <br /> Design Flow(gpd) Design Soil Application Rale(gpds1) Dispersal Area Required(si) Dispersal Area Proposed(sO) System Elevation <br /> 600 0.4 1500 1500 100.0',102.0' <br /> Vi.Tank Info Capacity In Total N of Manufacturer <br /> Gallons Gallons Unit, -s6, S 1 .N <br /> New Tanks Existing Trots d y N vii $5 . <br /> Sc'""o`Laa'agTank 700/550 1250 1 Crest x <br /> Dosing Chmber <br /> VII.Responsibility Statement-1,the undersigned, es nsiWllty for Insto)lation of the POWTS shown on the annched plans. <br /> plumfbers Name(Print) P Signet MP/MPRS Number Business Phone Number <br /> (Crl.e.'- ��.,ti_- I _. Zxiric9 g73_-y qo3 <br /> Plumbre:s(ddum(Street,City. te,Zip Code) / <br /> )f YO on c2:-, �d r t./..r 1 rYf <br /> VIII.County/Department Use Only <br /> P(Approvcd ❑Disapproved Permit Fee Date issued Issuing Agent S' ure <br /> ❑Owner Given Reason for Denial $7C/ . CO (24-'20/6 c <br /> IX.Conditions of-Approval/Reasons for Disapproval <br /> Attach to camplele piens for the spurts Part submit to the County only an paper not less than II lC e II Whet In six <br /> SBD•6398(R.11/I 1) <br />