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3 <br /> `�a� �� Industry Services Division County <br /> I_ 11 1400 E Washington Ave a, "' Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 tt7 <br /> Madison,WI 53707-7162 J L <br /> `�caliGAV'� �— CC//�� <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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 28841 Birch Island Lake Rd. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> James Vandenberg 18148 <br /> Property Owner's Mailing Address Property Location <br /> 3530 Bay Highland Circle <br /> Govt.Lot 3&4 <br /> City,State Zip Code Phone Number 'G, /4, Section 18 <br /> Green Bay,WI 54331 (circle one) <br /> T40N R14Eor�!) <br /> H.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling—Number of Bedrooms_ 6 Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# <br /> ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> ® Town of Scott <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ® New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS S stem/Com onent/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of 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 Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 642 660 9625 <br /> .7 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of <br /> Gallons Units Manufacturer 0B <br /> New Tanks Existing Tanks d; U A <br /> Septic or Holding Tank 1000 1600 I Weiser ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber 600 ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P is S'gnatu MPIMPRS Number Business Phone Number <br /> Kell Ferguson 224069 7154164597 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W9502 Dock Lake Road Spooner WI 54801 <br /> VIII.Conn /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> 7�7 0 <br /> ❑ Owner Given Reason for Denial $ 3 /J• 7 I/_&_/6 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �o�bsra� i5os�� = /Ue GvPLL o.v d/o/ /�a.v <br /> EUNY ED <br /> APR —6 2016 <br /> Attach to complete plans for the system and submit to the County only an paper not less than 8 1121 11150MIM/BOUNTY <br /> ZONING <br /> SBD-6398(R03/14) <br />