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commerce.wi.gov County Safety Madison and,BuildiWI ngs Division 53707-7162 Dane iSCOn s i n 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) Department of Commerce _ 13-2022-00328 State Transaction Number Sanitary Permit Application PWTS-1122502788-C 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 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 GARY L NOLDEN 0508-192-6011-0 Property Owner's Mailing Address Property Location 733 FRITZ RD Govt Lot. City,State Zip Code Phone Number SE 1/4 NW 1/4 Section 19 BELLEVILLE,WI 53508 Not Provided Township: 05 N: Range: 08 E II.Type of Building(check all that apply) Lot Number Subdivision Name 1 ® 1 or 2 Family Dwelling-Number of Bedrooms: 3 Block Number CityNillage/I'own of ❑ Public/Commercial-Describe Use: CSM Number ❑ State Owned-Describe Use: 16103 III.T e of Permit:(Check only one box on line A.Complete line B if applicable) ❑ Re lacement ❑ Permit Revision ❑ ❑Other Modification to Existing System(explain) A. H New System System p ❑ Treatment/Holding Tank Replacement Only B. ❑ Permit Renewal Change of Plumber ❑ Permit Transfer to List previous Permit Number and Date Issued Before Expiration 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 ❑Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component: ❑Pretreatment device: V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation 450 .6 750 750 933.0 Capacity in Gallons Total #of I e - !0 VI. Tank Info: Gallons Units Manufacturer ° c u New Tanks Existing Tanks °"U in Septic/Holding Tank 1,000 0 1,000 1 Crest ✓ Dosing Chamber 600 0 600 l Crest ✓ 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 Travis Desmet Permit application completed online 1002082 (608)424-3014 Plumber's Address(Street,City,State,Zip Code) 7869 County Highway D,Belleville,WI 53508- VIII.County/Department Use Only ❑Disapproved Permit Fee Date Issued Issuing Agent Signature B Approved ❑Owner given reason for denial $ 1,085.00 12/02/2022 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.