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commerce.wi.gov Safety and Buildings Division Cowry <br /> 201 W.Washington Ave.,P.O.Box 7162 E T <br /> i sco n s i n Madison,Wl 53707-7162 Sanitary Per?mit Number(to be filled in by CO.) <br /> Mpanmest of Consonance -4-3ra <br /> Sanitary Permit Application Stare Transaction Number <br /> In accordance with s.Comm.83.21(2);Wis.Adm.Code,submission of this foam to the appropriate governmental (1 ) <br /> unit is required prior to obtaining a sanitary, permit. Now: Application forms for satcawned FOWrS are Project Address(if diffiamt thanmailing address) X� <br /> submitted to the Department of Commerce. Personal information you pmvide may be used for secondary <br /> purposes in accordance with the PrivacyLaw,s. 15-04(1 m,Stars. <br /> 1. Application Information-Plan Print All Information <br /> Property Ow 's Name - parcel ao^� � 0�_-� `✓ <br /> TN �' N a� p( `y <br /> Property Owner's Mailing Ad S�D Ave.of Property Local <br /> 1/b' dQL 2! ACS- Govt Lot <br /> City.Sate -St.po". , m/V Zip Cade Phone Number Sat/ %, S�rJ V, Section <br /> (Jt.t,n ove/ . (circle oro <br /> -S O t= '///— 70 T Yo N: R E <br /> 11. a o(Buildin (check a6 that apply) Lor# <br /> �rr/ J-(, -6a6divleionN..r► <br /> ll/10[ZFamily Dwelling-.Number ofBdrtuems_ �_ __. _ ..-'_ <br /> Block N <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Numbper ❑Village of <br /> VIS 7 �fownoF ScaTT <br /> Ill.Type of Permit: (Check only one box on line A. Complete We B if applicable) <br /> A. ❑New System "placement System ❑Treawent'Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer ro New List Previous Permit Number and Dace Issued <br /> Before Expiration Owner <br /> I V.T e of POWTS S stem/Com aat/Devica Check all that Apply) <br /> Non-Pressurized In round O.Pressurized l.-Ground ❑ Ar-Grade i]Mound_>24 in.ofsuitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dia ersalfrratinat Area lafortastfone EZ IC40,W 9 - e ' rC6 s - <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation/• /o s. <br /> 00 yaS. G i 3, ios�n' <br /> os.a' <br /> V1.Tank Info Capacity inToad d of Manufacturercmir s Gallons Units 0 v w <br /> Ncw Taub Eaistioa Tanaka <br /> Septic orHoldiag-Tark <br /> owing Cha tber 1W <br /> VII.Responsibility Statement-1,the aedersigaed,mums responsibility for histanatlailLof the POWTS she"as the attached plana. <br /> Plumber's Name(Print) Plum t MP/MPRS Number Business Phone Number <br /> Plumber's <br /> 'r d <br /> Plumber's Address(Street,City.Slin,Zip Code) <br /> a 3 EElL <br /> /Ifpe444/� G;M" XP S ivvCe�� rc� SY?o/ <br /> 7l� Y!6—off <br /> Vill.Coca /De artment Use Only 4z <br /> Ef Approved Q Disapproved Permit Fee Dow Is ed Issu Signatume <br /> ❑Owner Given Reason for Denial S 325V - lvi'{A�20J0 <br /> IX.Conditions of ApprovnVRemms for Disapproval <br /> Anaeh to complete plans for the system and submit to the County only on paper not leu than a In x 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />