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to accordance with SPS 383.21(2),Wis.Aim.Code,submission of this form to the appropriate governmental unit 13 ~, Li 1 () - V 0 Li.. 9 <br /> is required prior to obtaining a sanitary permit. Notc Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> par Department accordance Safety and Professional Scares. Personal Slats. ay(pp I�.�,j trse� cry <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm1,Slats. K 1`// 3151 CTH J <br /> I Application Information-Please Print All Information <br /> �;°op Owner's Name Parcel#/ <br /> �Debra Kollberg FEB 2 9 2016 �" 0607-021-9510-0 <br /> Property Owner's Mailing Address Property Location <br /> Public Health MDC <br /> 2848 Trail View Road Envl"onmentaI Health GOVtyLol <br /> City,Stale Phone Number `/CIE �t, NE '/., section 2 <br /> Verona,WI /*COM).535 i" (circle one) <br /> II.Type of Building(check all that a y) ( Lot y ! / T 6 N; R 7 E or W <br /> ®I or 2 Family Dwelling-Number of ms 3 f/ 1 Subdivision Name <br /> i <br /> Block# . <br /> ❑Public/Commercial-Describe Use ❑City or <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Y 13657 ICJ Town of Springdale <br /> III.Type of Permit: (Check only one hex on line A. Complete line B II-applicable) <br /> A' 2 New System 0 Replacement System ❑TreatmemillolrEng Tank <br /> Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV,Type of POWs System/Component/Devicc (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade el Mound?24 in.ofsuitable soil ❑Mound<24 in.of suitabk soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Applt on Rate(gpdsi) Dispersal Area uired(sl) Dispersals l Proposed(si) System Elevation <br /> 450 C r 9;C) 6 L99. l 97.0' <br /> VI.Tank Info Capacity in Total #of M farmer <br /> Gallons Gallons Units u o'R o <br /> New Tanks Existing Tanks t c 3 g �,`+ i3 <br /> a u m ,., m iZ a o. <br /> Septic ar}folding Teak 1000 1000 1 Dalmaray x <br /> Dosing Chamber 600 600 1 Dalmaray x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POUTS shown on the attached plans. <br /> Plumber's Name(Print) 5ignwtm > MP/MPtS Number Business Phone Number <br /> SCO-+ l—oVPjic, f <br /> 22(0$52 . -4t... 314 <br /> Plumber's Address(Street,City,State,Zip Code) •. <br /> 1_I I LA e IA Poi ke l l/JS S 3`31 -1 ,,, , �\ <br /> VIII.Connty/Depa*meat Use Only _■�� <br /> Permit Fee Date , , Issui . ,u/ -� <br /> � / <br /> pptoved 0 Disapproved / <br /> 3 <br /> 0 Owner Given Reason for Denial ). __- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete piens for the system and submit to the County only on paper out less than 8 ail s I I Inches in sIxe <br /> SBD-6398(It.11/11) <br />