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Safety&Buildings t t <br /> Sanitary Permit Application 201 W.Washingt Ave. <br /> In accord with Comm 83..21,Wis.Adm. Code PO B(�73\2 <br /> `�5eon5in <br /> See reverse side for instnretit»�for completing this application Madison,WI 537 2 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to coun of <br /> Department of commerce [Privacy Law,S. 15.04(1)(m)] state <br /> Attach corn lete tans to the coun coo on] )for the s stem,on a er not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Pe it Nu Che revisi n to previous a lication State Plan I.D.Number <br /> big Location: <br /> I.A ication Information-Please Print al Information property Location <br /> Property Owner Name q �� <br /> ��� 1/4 1/4,S/ ' N,R or W <br /> Lot Number Block Number <br /> Property Owne?s Mailing Address /� I '/ / <br /> OUND rf - Subdivision Name por CSM Number <br /> p <br /> City,State <br /> Zi Code Phone Number <br /> 55D /-I 433-5737 JEANW JAWA qaE J✓ of _-14 <br /> ❑City <br /> II.Type of Building: (ch ck one) Z C3 village <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Town of OW <br /> vh/Y1 <br /> ❑ Public/Commercial(describe use): !��'r!�"�/ <br /> ❑ State-OwnedNearest Road <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) b <br /> �1 Parcel Tax Number(s) o <br /> A) L N44ew System 2. ❑Replacement 3. T Tank OnlReplacement of 4. ❑Existing <br /> System �!i`� <br /> System Date Issued <br /> Pemtit Number <br /> B) <br /> ❑A Sanita Permit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> coon-pressurized In-ground B <br /> ❑ Single Pass ❑Drip Line <br /> ❑Pressurized In-ground ❑Holding Tank <br /> A <br /> ❑ erobic Treatment Unit ❑Recirculating. ❑Other: <br /> ❑At- de <br /> V.Dis ersal/Treatment Area Information: <br /> Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> 1.Design Flow(Bpd) 2.Dispersal Area 3.Dispersal Area 4.Soil App Elevation <br /> Required Proposed Rate(G^Jday/sq.ft.) (Min./inch) �� <br /> 300 Z41 3 Z r---1 /00 3 <br /> Prefab ite Steel Fiber- Plastic <br /> Con- Con- B <br /> VI.Tank Capacity in Total #of Manufacturer Sass <br /> Gallons Gallons Tanks <br /> Information trete strutted <br /> New Existing <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> C 1000 �OoO I �JbKaJ�siD <br /> VII.Responsibility Statement <br /> I,the undersi ed,assume res onsibili for installation of the POWTS shown on the attached plans. Business Phone Number <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. <br /> Fl <br /> umber's Address(Street,City State,Zip Co e) <br /> rConvditions <br /> 0 <br /> partment Use Only <br /> Sanitary Permit Fee(Includes Groundwater Date sued Issuing ent i o stamps) <br /> Disapproved Surcharge <br /> Owner Given Initial Adverse yq <br /> etermination <br /> f Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />