Laserfiche WebLink
Industry Services Division County <br /> 4822 Madison Yards Way <br /> I={f= Madison,WI 53705 Sanitary Permit Number to be filled in by Co.) <br /> P.O.Box 7302 (� <br /> yt 5FN.23- -2C <br /> Madison,WI5302 ,� _� �JZp <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),Stars. <br /> I.Application Information-Please Print All Information 1U,31 od-� <br /> Property Owner's Name Parcel# <br /> Evergreen Haven LLC 07-024-2-39-14-14-2-01-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> 4221 Cheswick Ln <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> Virginia Beach VA 23455 /4, /4, Section 14 <br /> II.Type of Building(check all that apply) Lot# T 39 N R 14 E or <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms 5 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ❑Town of Rusk <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. New System ❑ Replacement System ❑ Other Modification to Existing System(explain) <br /> y p y g y ( p ) El 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 El Change of Plumber El Transfer to New Owner <br /> ist 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 /> 750 .7 1071 1098 97.5 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o <br /> New Tanks Existing Tanks c w p <br /> a U i y v z C7 r% <br /> Septic or Holding Tank 1645 1645 1 Wieser x <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assume re biljty for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu ber's Si MP/MPRS Number Business Phone Number <br /> Kelly Ferguson 224069 715-416-4597 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W 9502 Dock Lake Road Spooner WI 54801 <br /> VI.County/Department Use Only <br /> Permit Feed Date Issued J.Zent ** natyre <br /> a <br /> Approved ❑Disapproved $qQ� 9 /2;1d3 <br /> ❑Owner Given Reason for Denial ` <br /> Conditions of Approval/Reasons for Fisapproval <br /> so W. D <br /> - Ek, 51h� fi. �er� � P �� ��� cede. <br /> Z�, <br /> *,- k c A5 & �c a, S, SEP 1 1 2023 <br /> CountyL_ �Pvl f-3 , urnett <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x t 1 in es in viand Services Department <br /> -15D r�(,k 4-7`[� <br /> SBD-6398(R.02/22) W t WL,— w vvl,,� <br />