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In accordance with SPS3.21(2),Wis.Mn,.Code,submission of ' f t� • to �tttal unit <br /> t <br /> is required prior to obtaining a sanitary permit. Note:Application f o ed to Project Address(it different Than mailing address) <br /> the Department of Safety and Professional Semies. Personal Inf n <br /> purposes in accordance with the Privacy Law,s.15.04(1)(mi,Slats. <br /> L Application Information-Please Print All Information JAN 1 2 2016 <br /> Property Owner's Name Parcel 4 (C-"v' <br /> Gary Karls Public Health MDC L--- 0506-052-85364- <br /> Property Owner's Mailing Address Environmental Health Property Locution <br /> P.O. Box 12 Govt.Lot <br /> a City,Stale Zip Cade Phone Numbs NW ,µ, NW Y, Section 5 <br /> Mt. Horeb, WI 53572 219-9163 (circle one) <br /> T 5 N; R 6 E or W <br /> Ii.Type of Building(check all that npplyY ' \ Lot 4 <br /> ®I or 2 Family Dwelling-Number of Bedrooms <br /> 4 f1 Subdivision Name <br /> / Block# <br /> ❑Public/Commercial-Describe Use ` <br /> ❑City or • <br /> ❑State Owned-Describe Use CSM Number 1//7 -, ❑Village of <br /> f ®Town of Perry <br /> ....!?w{aoset:i CSM <br /> III.Type of Permit: (Check only one box online A. Complete line If applicable) <br /> A ei New System 0 Replacement System ❑TreatmenNiokn 'bnk Replacement Only Other Nlodiiication to Existing S yst em(e xp lain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Penult Transfer to New Last Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/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) 0 Pretreatment Device(explain) <br /> V.Dispersal/Prentment Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(s) Dispersal Area Proposed(si) System Elevation <br /> 600 1.0" 0, 600 (; .cc r> ;21ri t 103.7' <br /> VI.Tank Info • Capacity in /Total 4 or Mmultacturer <br /> Gallons Gallons Units o$ r, <br /> Nov Tanks Existing Tanks . g v t' y 1 i >� <br /> etU rn K rn is0 F. <br /> Septic or/folding Tin* 819/467 1286 1 Meade x <br /> Dosing Chamber 650 650 1 Meade x <br /> ViI.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Signorine MP/MFRS Number Business Phone Number <br /> ALLpezisv,./ 1'i. Nil t Ni(4-61-7-1 _4,-, 1,-). '''--—b .2--o ((Q 5 ( Obi—8 i 03 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> L9 t3 C(,)i. i Y L-1-1(r,biIA.'AY K t \-,JAuNA-i-er td( 53 597 <br /> VIII.County/Department Use Only - <br /> ❑Approved ❑Disapproved <br /> Permit(Fee Date Issued Lssiri -gnature } <br /> ❑Owner Given Reason for Denial Sif h (p G� J� /6 /'� <br /> I,`.Conditions of Approval/Rensons for Disapproval <br /> / / '`: <br /> C?' <br /> f2 .1.41 <br /> e-X;,r, €ra 'fir/ kAev'6'- <br /> Attach to complete plans for tiro system and submit to the County only on paper not less than 8 2 s I1 Inches In size <br /> SBD-6398(R.i 1/1 I) <br />