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Industry Services Division County <br /> 4822 Madison Yards Way <br /> • $R �=� Madison,WI 53705 Sanitary Perm►tN b(to be filled in by Co.) <br /> S P.O.Box 7302 <br /> Madison,WI 5302 ja <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary 7508 County Hwy B <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I.Application Information—Please Print Alt Information <br /> Property Owner's Name Parcel# <br /> Tyler Corrigan 07-030-2-38-16-08-04-03-000-01601 <br /> Property Owner's Mailing Address Property Location <br /> 1398 Belmont Drive <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> Woodbury MN 55125 <br /> S1/2 SE , Section 08 <br /> II.Type of Building(check all that apply) Lot# T 38 N R 16 E or <br /> l or 2 Family Dwelling—Number of Bedrooms 4 Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# <br /> 0 City of <br /> ❑State Owned—Describe Use <br /> CSM Number 0 Village of <br /> Town of Siren <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. rol <br /> ew System ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank ,In-Ground ❑At-Grade ❑ Mound ❑ Individual Site Design ❑Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber CITransfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV,Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 .7 857 858 98.5 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units s, 0.) o <br /> New Tanks Existing Tanks c aui <br /> 0 <br /> n w C7 CL <br /> Septic or Holding Tank 1200 2000 1 Wieser x <br /> Dosing Chamber 800 <br /> V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Kelly Ferguson 224069 715-416-4597 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W9502 Dock Lake Road Spooner WI 54801 <br /> VI.County/Department Use Only <br /> ❑Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> 0 Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <br /> REVS SEt) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x II inches in size <br /> SBD-6398(R.02/22) <br />