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RECEIVED Coway <br /> j DEC P4 tlna Buf�ingss Divit ton Dane <br /> Public Health MDC 2D1 W.Washington Ave.,P.O.Box 7162 Smdmy Pk nth e m bapobe lilkd ion byCo.) <br /> Maflsm.WI ls3707 7162 <br /> lEnvironmental Health 3-,)T j Q(�3 `� <br /> �-V <br /> Sanitary Permit Application StateTimeefknNteobie <br /> Is=cordon=with BPS 313.21(2).Wis.Adn Cade.submission oftb6 Rata to the apFtopiata govmmtemd mit <br /> is regained prior looblaioidga=iky pamb.Note;Applearim rams hx aleteowaed POWfSamsubmitted to Project Address fifdDfcmt awtmdihtg address) <br /> the°eparuomt of Safety and Profemkmd Barks.Rama.information you provide say ba used for scconchry <br /> Purposes in arsmdaam with de Privacy Law.a,15.040 Rot Stan. Bergum Road <br /> L Appliaitminformadoa-Please Print All Information <br /> Property.Owner's Nwoo Pend I <br /> Chad&Lynn Kitsemble 0606-022-0680-0 <br /> Property Owner's*gin Addt® Property Loalloo <br /> 205 Heather Court . Govt.Lot <br /> City,State s 1'. SE ts, NW Ss..section 2 <br /> Mt Horeb,WI e 53572 T 6 N R 6(Mete <br /> U.Type of BuBdag(cheek dl that apply/ rot if <br /> I3 1 or Fatally Dwelling-Number of:- 3 1 Subdivision Name <br /> Bbara . <br /> ❑PrdtedCaameteiaf-Describe Use - ❑city of <br /> ❑SmeOwned-Describe Use <br /> Cal Number ❑Village of <br /> 13900 i9 Town of Blue Mounds <br /> Ili.Type of Permit:(Cheek only ene box on line A.Complete Rae Elf applicable) <br /> A Z<I New System ❑Replacement Systen ❑Trestmaw►iakBogTank Replacement Only ❑Other MoellBcodoo to Existing System WOMB <br /> List Previous Permit Nturtb <br /> B. ❑Permit Renewal ❑Permit Revision ❑t oflkofi Toaster❑Permit To sterto New a sod Dote Issued <br /> BcWroExpirattion Owner <br /> IV.Type of PW S Syste mponmNDoyle=.(Omit alt that apply.) <br /> ❑Nom-PtessaiedJo-Gotmd ❑Pressurized to-Ground ❑At-Gawk ❑Mooed kle to.of satiable sot3 i9 Mound<24ha.of suitable sol. <br /> ❑IloldlogTeak ❑Other Disposal Campmaa(espMk1_ ❑Prememtea Device(explain) <br /> V.DispersaffT eatment Area Information: <br /> Design Flow WA Desipt Soil AppfW' Dispersal Ater fe) Dispersal A Proposed fst) System Elevation <br /> 450 1.0 04, 450 I S'a 456/fig/ 96.4' <br /> VI.Tank IMO is TaRas Meaute <br /> Gallons CT ocer <br /> 9 <br /> We Teaks t�atteaTatdw rt i y 3 11 a8. <br /> Tak 1250 -- 1250. 1 Crest X <br /> Das*Claedaer 750 — 750 1 Crest x <br /> VII.Responsibility Statement-I,the aadesalpee, responsibility for lastnllothmr of the IOWTS shows on tie adoehedptlane. <br /> 's Name(Print) Pbmhe tea MPIIRPRI eafic <br /> . , Bud�PoneNumber <br /> of}/ ,s t4, •A atzeu �0.�76- <br /> / ' <br /> Plumber's Addicts(Soca.ue TCde <br /> f <br /> VIII.County/Department Use Only <br /> Permit Pee <br /> Data Lowed Icalog <br /> Approved Disapproved 0 owterGron Reason err Dental S /2�i Y I r ?A� <br /> < / <br /> IX.Conditions of Approval/Reasons for Disapproval f��� � e`A /� 9 LYy ryA <br /> 02 74a m 3 �r-ice /�-rlr ° e JI.�-E <br /> FANK rtPu.- CBA'(O*c fr, ,g,iG ef-utt 7 r,Ar0 / 7.t <br /> ct�444 4vi‹.- <br /> Attach b atepl.l.µo for fiesrsMS and seat to the Camay sty an pew oar ion thaw a re xit lesions lasts <br /> SBD-6398(R.11/11) <br />