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Industry Services Division County <br /> 47, <br /> 4822 Madison Yards Way <br /> i s 4 t Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7302 <br /> AnS-�3 -/2,l !/ <br /> Madison,WI 5302 r 25 g� <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 27606 Hill Road <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Charles&Betty Knutson Rev.Trust 07-028-2-40-14-25-5-05-004-02100 <br /> Property Owner's Mailing Address Property Location <br /> N 8228 900'Street <br /> Govt.Lot 4_ <br /> City,State Zip Code Phone Number <br /> River Falls WI 54022 1/a, /., Section 25 <br /> 11.Type of Building(check all that apply) Lot# T 40 N R 14 E oeq <br /> ❑ 1 or 2 Family Dwelling—Number of Bedrooms 3 4 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 bog on line B.Complete line C i <br /> applicable.) <br /> El New System ^Replacement System ❑ Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B' ❑ Holding Tank 7In-Ground ❑At-Grade ❑ Mound ❑ Individual Site Design ❑Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑Transfer to New Owner 1st 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 Ele at� <br /> 450 .7 643 652 �4 y <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o ,�, 2 <br /> RS U U U y <br /> New Tanks Existing Tanks o ;; R <br /> a. U n ti Ln <br /> Septic or Holding Tank 1000 1600 1 Wieser x <br /> Dosing Chamber 600 <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 7154164597 <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 /> 'Approved ❑Disapproved Permit FFeee� Date Issued Issuing gent Si atu <br /> ❑Owner Given Reason for Denial $3 75 7/,;�I l� <br /> Conditions of Approval/Reasons for Disapproval <br /> M eel G I 5 e�,�,c�5 �- 5�� 'r� 7 4, 3 75 <br /> USC. Zv li4r 153 v v <br /> T'K OW - bt d��l� % "11V of 1� d JUL 2 0 2023 <br /> 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 <br /> Land Services Department <br /> SBD-6398(R.02/22) <br />