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.._ <br /> ,tt"----;. ,, Industry Services Division County" <br /> 4822 Madison Yards Way 15,,,/hG <br /> A+ <br /> `` Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> \! '_ /-' P.O.Box 7302 �2 ( ' 41 <br /> +'—'_',4-: Madison,WI 5302 <br /> �y��r <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 }, <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information 28843 ooney Lake Drive <br /> Property Owner's Name Parcel# <br /> Charles Damaske 19007 <br /> Property Owner's Mailing Address Property Location <br /> 8880 N.Hawk Haven Drive Govt.Lot 16 <br /> City,State Zip Code Phone Number <br /> Hayward WI 54843 /<, /<, Section 11 <br /> IL Type of Building(check all that apply) Lot# T 40 N R 14 E or(9 <br /> 41 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ❑Town of Scott <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. <br /> New System ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B' ❑ HoldingTank KIn-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design <br /> gn ❑Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑ Transfer to New Owner <br /> 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 /> 300 .7 428 440 96 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units ° o 'd o <br /> New Tanks Existing Tanks oft v. T) 1'aU in ., e, 4., o a.. <br /> Septic or Holding Tank 750 750 1 Weiser x <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu er's Signature MP/MPRS Number Business Phone Number <br /> Kelly Ferguson t 1)% AAL2.e 14.. 224069 715-416-4597 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W9502 Dock Lake Road Spooner WI 54801 <br /> VI.A County/Department Use Only <br /> Cal A roved 0 Disapproved <br /> Permit Fee P� Date IssuedIs '] i n Age Signatu <br /> rr ❑Owner Given Reason for Denial $375 6I(6l va �- u <br /> Conditions of Approval/Reasons pproval <br /> (leefr Q S .�i' ---kv 1125 <br /> C):?e uSeei iteds +v he s e,,-�'ec( � �' ,G C� C 0 M C, <br /> P (Asp �• D <br /> I SUN 01 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inch,c in size <br /> etlrnett County <br /> SBD-6398(R.02/22) Land Services Department <br />