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commerce.wi.gov County Safety and Buildings Division Dane i sco n s i 11 201 W.Washington Ave.,P.O.Box 7162 Madison,WI 53707-7162 Sanitary Permit Number(filled in by Co) Department of Commerce 13-2018-00173 State Transaction Number Sanitary Permit Application In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental 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 MICHAEL KEMP 0610-352-9510-0 Property Owner's Mailing Address Property Location 316 W MILWAUKEE ST Govt Lot. City,State Zip Code Phone Number SE 1/4 NW 1/4 Section 35 STOUGHTON,WI 53589 Not Provided Township: 06 N: Range: 10 E H.Type of Building(check all that apply) Lot Number Subdivision Name 1 0 1 or 2 Family Dwelling-Number of Bedrooms: 3 Block Number CityNillage/Town of ❑ Public/Commercial-Describe Use: CSM Number ❑ State Owned-Describe Use: 14248 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) (?1 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 450 .6 750 780 92.0,93.0 Capacity in Gallons p ti Total #of ro o VI. Tank Info: Gallons Units Manufacturer a o n 0. New Tanks Existing Tanks U Septic/Holding Tank 1,330 0 1,330 1 Dalmaray ✓ Dosing Chamber 750 0 750 1 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 William Steinke Permit application completed online 227999 (608)754-6100 Plumber's Address(Street,City,State,Zip Code) 2930 N.Harmony Townhall Rd.N,Janesville,WI 53548- VIII.County/Department Use Only ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature 0 Approved ❑ Owner given reason for denial $ 431.00 06/19/2018 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.