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unitary Permit Application <br /> Safety&Buildings Division <br /> In accord with Comm 83.21, Wis.Adm. Code p 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application 15 Box 7302 <br /> `�SCOIfSin Personal information you provide may be used for secondary purposes Madison, to county 7302 <br /> Department of Commerce (Privacy Law,s. 15.04(I)(m)] (Submit completed forth to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)fjx the syLtem.on paper not less than 8-1/2 x I I inches in size. <br /> County n Stare Sani Permit Number ck i�f�revi£ionn'w S io application State Plan 1.D.Number <br /> rS U r N)-f_i �F of ) n <br /> 1.Application Information-Please Print all I formation Location: v 1 <br /> Property Owner Name ME Property Location t' <br /> Q.1'1 d SOSk'J / "e �1-d� (jI S� 1/4 ! EEIA,S I T�q,N.RPE W <br /> i imperty Owner's Mailing Address Lot Number Block Number <br /> u2�71 <br /> City,State a Zip ode Phone Number Subdivision Name or CSM Number <br /> I (?f S-- I <br /> II Type of Building: check one) ❑City <br /> p7L 1 or 2 Family Dwelling—No.of Bedrooms:_ ❑Village <br /> J Public/Commercial(describe use):State-owned B Town of <br /> RAS <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road. <br /> c 4,j,uc/2 d <br /> A) I. New System 2. ❑ Replacement 3. 13 Replacement of 4. ❑ Addition to Parcel Tax Numbcr(s) <br /> Svstem I Tank Onlv Existing System 11,2 44 - -.3/D/—e%02 ?bb <br /> B) <br /> 11 Permit Number Date Issued <br /> A Sanitary Permit was oreviousiv issued <br /> v.Type of POWT System: (Check all that apply) <br /> ,Kion-pressurized In-ground ❑ Mound ❑Sand Filter ❑ Constructed Wetland <br /> I Pressurized In-ground ❑ Holding Tank ❑Single Pass ❑ Drip Line <br /> J At-grade ❑ Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> Dispersal/Treatment Area Information: <br /> Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed 'a <br /> teJday/sq.R) (Min./inch) q Elevation <br /> 600 50 r <br /> 0 ) • — ! � 10/ Av G, <br /> i1 Tank Capacity in Total I 4 of Manufacturer Prefab Site Steel Fiber- Plastic <br /> nformation Gallons Gallons Tanks Con- Con- glass <br /> New I Existing trete strutted <br /> e <br /> _iqflc Tanks Tanks <br /> ` ❑ ❑ EI <br /> Se ❑ <br /> t 4-LL ❑ ❑ ❑ ❑ ❑ <br /> II Responsibility Statement <br /> I,the undersigned,assume responsibilitVor installation of the POWTS shown on the attached plans. <br /> :umber's Name(print) PI beds Sign tu no stamps): MP/MPRS No. Business Phone Number <br /> e�� er' v�un1 2 Z .. O <br /> 'umber's A (StreeC City,State,Zip Code) <br /> Lj? o)� - Dec . L,-Up- 12d . SPodaale� Li I S'48oI <br /> III County/Department Use Only <br /> ❑Disapproved I Sanitary Permita(includes Groundwater Date Issued Issuing Age t Si ps) <br /> gkproved ❑Owner Given Initial Adverse Surcharge Fee) �7 <br /> Determination ' r <br /> Y Conditions of Approval/Reasons for Disapproval: ( ' <br /> ,OCT 17 2U01 <br /> ZONING <br />