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county <br /> Industry Services Division /�r^,�n <br /> a 1400 E Washington Ave Sanitary Pennit Number to be tilled in b Co.) <br /> \ SPS . `I P.O. Box 7162 ( y <br /> ',• 5" Madison, WI 53707-7162 -S/ tt <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacv Law,s. 15.04(1)(m),Slats. 7S<.1f, La �p ry p y <br /> 1. Application Information-Please Print All Information S <br /> Property Owner's Name Parcel# <br /> Kt>n Cook <br /> Property Owner's Mailing Address Property Location <br /> I.S Of 4Q. o o bl 4th`[ <br /> Govt.Lot <br /> City,State Zip Code Phone Number , <br /> /,, b, Section -( <br /> W e(,1 � ./ (//j SG($e►3 (circle one) <br /> II.Type of Building(check all that apply) Lot ft <br /> T y0 N; R /b E or® <br /> ❑ Ior2Family Dwelling-Number ofBedrooms -L Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ Ciry o <br /> ❑State Owned-Describe Use I CSNI Number ❑ Village of <br /> ❑ <br /> Town of a lLw <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replact!Tnent System X Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ❑ Cham ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal ❑ Pznnit Revision oe of Plumber <br /> Before Expiration Owner a&:3 �7 J _A <br /> IV.Type of POWTS Svstem/Com onent/Device: (Check all that a Iv) 1 2 <br /> JO Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 3190 1 K3A exist. <br /> VL Tank Info Capacity in -fotal #of Manufacturer <br /> Gallons Gallons Units X. <br /> New Tanks Existing Tanks <br /> 2J vi <br /> Septic or Holding Tank 7S-O 7SO <br /> Dosing Chamber SOO <br /> VII. Responsibility Statement- 1,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 /> Plumber's Address(Street,Ciry;State,Zip Code) <br /> d 77 G t<l ` 3S SWI-3 <br /> Vlll.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee O Date Issued Issuing Agent Si lure <br /> ❑ Owner Given Reason for Denial S 3�5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system anti submit to the County only on paper not less than S v±s 11 is size <br /> OCT 28 2015 <br /> sBD-6398(R03 13) BURNETT <br /> W �� i <br />