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commerce.wi.gov County Safety and Buildings Division Dane D ero ii s i fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) Madison,WI 53707-7162 Department of Commerce 13-2017-00381 State Transaction Number Sanitary Permit Application In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate Project Address(if different than mailing) governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-owned 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 MICHELLE FULLER 0707-143-9205-0 Property Owner's Mailing Address Property Location 8393 PINE HILL RD Govt Lot. City,State Zip Code Phone Number SW 1/4 SW 1/4 Section 14 CROSS PLAINS,WI 53528 Not Provided Township: 07 N: Range: 07 E II.Type of Building(check all that apply) Lot Number Subdivision Name O 1 or 2 Family Dwelling-Number of Bedroo Block Number CityNillage/Town of ❑ Public/Commercial-Describe Use: CSM Number Town of Cross Plains ❑ State Owned-Describe Use: 14655 III.Type of Permit:(Check only one box on line A.Complete line B if applicable) ❑Other Modification to Existing System(explain) A. Q New System ❑System Replacement CI Treatment/Holding Tank Replacement Only Change of Permit Transfer to List previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ g ❑ Before Expiration Plumber New Owner _ IV.Type of POWTS System/Component/Device:(check all that apply) ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At Grade ❑Mound>24 in.of suitable soil El 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 .6 600 600 101.5 Capacity in Gallons :: c > oA Total #of Manufacturer w„ a U ,s-; n VI. Tank Info: Gallons Units cy U p a-, New Tanks Existing Tanks v, a Septic/Holding Tank 1,300 0 1,300 Dalmaray ✓ Dosing Chamber 750 0 750 Dalmaray ✓ 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 Ben Magnuson Permit application completed online 207180001 (608)438-6945 Plumber's Address(Street,City,State,Zip Code) 5192 County Rd J,Mt Horeb,WI 53572 VIII.County/Department Use Only ❑Disapproved Permit Fee Date Issued Issuing Agent Signature Q Approved 0 Owner given reason for denial $ 1,246.00 11/20/2017 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.