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Safety&Buildings Di stun <br /> ry Permit Application 201 W.Washington Ave. <br /> EM :7� <br /> ith Comm 83.21.Wis.Adm. Code PO Box 7302 <br /> sconSininstructions for completing this application Madison,WI 53707-7302 <br /> ou provide may be used for secondary purposes (Submit completed form to county if not•gent of commerceivacy Law,s. 15.04(1)(m)) state owned. <br /> Attach complete plans(to the countyco only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> S tary Permit Number ❑Check i evision to previous application State Plan 1.D.Number <br /> SSa <br /> L + lication Information-Please Print all Information Location: U� <br /> Property Location <br /> Property Owner Name AlW114��� <br /> � r V S 114 S 3 TJ�N E or <br /> Lot Number Bloek Number <br /> Property Owner's Mailing Address <br /> G jr-41�i /1l <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> / ( ❑City <br /> II Type of Building: (check one) ❑village <br /> 1 or 2 Family Dwelling—No.of Bedrooms: ,®Town of <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-owned Nearest Road <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) a0,�S <br /> A) 1. ❑New System 2. WReplacement 3. ❑Replacement of 1 4. ❑Addition to Parcell Tax Numbgr s <br /> System Tank OnlyExistingS stem M (( <br /> 8) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) ❑Sand Filter ❑Constructed Wetland <br /> ❑Non-pressurized In-ground ❑Mound <br /> ❑Pressurized In-ground Hyl Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade O Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.R) (Min./inch) Elevation <br /> VI Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing <br /> Crete structed <br /> Tanks Tanks e ❑ ❑ ❑ <br /> (oda © �GUJ tJ/{Ltl <br /> ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> the undersi ed,assume re onsibili for installation of the POWTS sho MP/MPRS No.it on the lens• Business Phone Number <br /> Plumber's Name(print) Plumber's Signature(no stamps): 3 <br /> : <br /> a6 <br /> umber's Address(Street,City,State,Zip <br /> 'A19 ('11 4e-&A 4e-&AG y / <br /> VIII County/Department Use Only <br /> :13Disapproved Sanitary Permit Fee(Includes Groundwater Dau issued Is t Agent 'gnature(Nostamps) <br /> Approved wner Given Initial Adverse Surcharge Fee) ¢�O l� O,X1 ermination Y' O <br /> DL Conditions of Approval/Reasons for Disapproval: <br />