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\I C. -,' U - .. - --- - ni ID 3 R i I D BID .)`)i-/33 <br /> • commerce.wl - " .ings Division County <br /> FEB 1241 11'''.shit; • Ave.,P.O.Box 7162 DANE <br /> 1 sc o n s In Madiso-1,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department°f c°mt>rerce Public Health MDC 5 17 f l <br /> Sanit. • , • •• e al H • ( . State <br /> __//Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental YT'�' /'-'vim lJ 9842-/ <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Kellesvig Street <br /> purposes in accordance with the Privacy Law,s. 15.04(lxm),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> O54/t 0' -DC s=-9543-f <br /> Holly&Steve Kellesvig <br /> Property Owner's Mailing Address Property Location <br /> P.O.Box 382 Govt.Lot <br /> City,State Zip Code Phone Number SE 1/4,SE'/., Section 6 <br /> Mt.Horeb,WI. 53572 (608)437-7336 — <br /> T6N R 7 <br /> II.Type of Building(check all that apply) Lot# <br /> 13/1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 8358 <br /> X Town of Springdale <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. <br /> L+(New System 111•stem Replacement System ep y ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Pemut Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Permit Transfer to New <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 L?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 Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 1.0 600 630 104.5 inv <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units p o o u <br /> New Tanks Existing Tanks y o N Z I = <br />