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Industry Services Division County <br /> `• 4822 Madison Yards Ways <br /> Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7302 �� •-�� <br /> � r <br /> Madison,WI 5302 — L,�F d <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),Slats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Shawn Novak 07-028-2-40-14-25-5-05-003-01060 <br /> 5 <br /> Property Owner's Mailing Address Property Location <br /> 1344 West Point Road <br /> Govt.Lot 3 <br /> City,State Zip Code Phone Number <br /> Spooner WI 54801 708-305-3708 y, /,, Section 25 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 14 E o <br /> 1 or 2 Family Dwelling-Number ofBedrooms 2 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> XTown 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. New System ❑ Replacement System g y (explain) (explain) <br /> ❑ Other Modification to Existing System ex lain) El Pretreatment Unit <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 ❑ Transfer to New Owner 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 /> 300 .7 428.5 452 94.3 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units fl 2 c <br /> lO U U <br /> New Tanks Existing Tanks o y <br /> a U n ti vo w C7 Ci <br /> Septic or Holding Tank 1060 1060 Infiltrator 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 224069 7154164597 <br /> 7 <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 ❑Disapproved Permit Fee Dat Iss eed� Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <br /> APR 19 2024 <br /> gijrnAtt County <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 lnchestwi#Services Department <br /> SBD-6398(R.02/22) -$ 175 —ceQ ���� <br />