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- - -�` - 201 W.Washington Ave <br /> x 73W, <br /> Visconsin <br /> In accord with Comm 83.21.Wis.Adm. Code See reverse side for instructions for completing this application Madison.Burl 5038707-730: <br /> Personal information you provide may be used for secondary purposes <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed forth to county if no <br /> state owned <br /> Attach complete plans(to the county copy only)far a system,on paper not less than 8 12 x 1 I inches in size. <br /> County State Sanitary Permit Number ❑gheck if revi;ion to previous kation State Plan 1.D.Number <br /> I.Application Information-Please Print all I formation k Location: <br /> Property Owner Name Property Location <br /> 91'e, Yi5 I/4,S 101/4•S 3 S T 3 ix RI'k or <br /> Property Owners Mailing Address \\ Lot Number Block Number <br /> °' <br /> 2 r-z r / V <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> SY2 o,,>Y,e V S U 1 ( Al <br /> It Type of Building: (check one) ❑City <br /> 0 1 or 2 Family Dwelling-No.of Bedrooms: 13 Village <br /> Publie/Commercial(describe use): 81 Town of /� <br /> ❑ State-owned RUS/� <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> e e <br /> A) I. ❑New System 1 2 d Replacement- 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System <br /> Permit Number Issued <br /> 13A Sato Permit was previouslyissued <br /> N.Type of POWT System:(Check all pl <br /> A Non-preuttrizal In-ground Mound a Sand Filter ❑Constructed Welland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V D' [/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersalfuea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 1 6.System Elevati Final Grade <br /> Required Proposed Ratc(Gals.lday/sq.ft) (Min./moh) 7j Elevation <br /> ys0 37✓ 3Ka 'Z NA 7G, 6 <br /> VI Tank Capacity in Total 1 #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete strocted <br /> Tanks Tanks <br /> SL ;G Dov p /ooD <br /> � a ❑ a ❑ <br /> v (o0a b Gay <br /> VII Responsibility Statement <br /> I the undersigned,assume ns <br /> �ibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Naar(print) Plumber's Sipsuire(no ): MP/MPRS No. Business Phare Number <br /> crt f� i e e a 7 7i a <br /> Plumbers Address(Street,City,State,Zap <br /> 9P 6I e 5 51 <br /> VIII County/Department Use Only <br /> 13 Disapproved Sanitary Permit Fee(Includes Groundwater Dao Issued Issw Signature(No stamps) <br /> Approved ElOwner Given Initial Adverse Surcharge Fee) 1750 D i <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br />