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. , . S commerce.wi.gov County Safety and Buildings Division Dane '�rO fl S I r 201 W.Washington Ave.,P.O.Box 7162 Madison,WI 53707-7162 Sanitary Permit Number(filled in by Co) Department of Commerce 13-2018-00020 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 3221 STATE HIGHWAY 134 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 HOLTZMAN REV LIVING TR,JON E 0712-364-9000-4 Property Owner's Mailing Address Property Location 3221 STATE HIGHWAY 134 Govt Lot. City,State Zip Code Phone Number SW 1/4 SE 1/4 Section 36 CAMBRIDGE,WI 53523 Not Provided Township: 07 N: Range: 12 E II.Type of Building(check all that apply) Lot Number Subdivision Name El 1 or 2 Family Dwelling-Number of Bedrooms: 4 Block Number City/Village/Town of ❑ Public/Commercial-Describe Use: CSM Number TOWN OF DEERFIELD ❑ State Owned-Describe Use: III.Type of Permit:(Check only one box on line A.Complete line B if applicable) ❑ Replacement ❑Other Modification to Existing System(explain) A. El 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 I l 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 600 .6 1,000 1,020 102.0 Capacity in Gallons Total #of as Ti-' N o — to N VI. Tank Info: Gallons Units Manufacturer a c p a New Tanks Existing Tanks U is Septic/Holding Tank 1,286 0 1,286 1 Meade ✓ Dosing Chamber 650 0 650 1 Meade ✓ 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 Steve R Crosby Permit application completed online 227009 (608)849-8771 Plumber's Address(Street,City,State,Zip Code) 7361 Darlin Drive,Dane,WI 53529- VIII.County/Department Use Only ❑Disapproved Permit Fee Date Issued Issuing Agent Signature El Approved ❑ Owner given reason for denial $ 1,246.00 02/06/2018 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.