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• sT of - I'iZ 7 ) of <br /> Safety& Buildings Dn,Nmn <br /> Sanitary Permit Appicaden )til w <br /> In accord with Comm 83.2 1,Wis.Adm. Code <br /> ro,„nu•r..e Personal information you provide may be used for secondary purposes (Submit Completed to,,,,t. ,• <br /> (Privacy Law,s.15.04(1)(m)] d_� <br /> Attach complete plans(to the county copy;::� - - - x 1 I inches.size. ---iii <br /> YrJB-1 State Sani Pcmut Number ❑Check ifreviai pr�viotu_ap4liiati;.r. State P;:n I.D.Nwnber <br /> 1 .sf a_ 5� <br /> I. A licattun Informatinr-Pleas Print all Infrrrr.ott.... Location: <br /> ),,lie, damer'1 -- Property Location (]� <br /> JCo L Le Ann LLLA\d iter SIE 1/4 551/4,s <br /> -,•;xc. �1..,,: \lalling Address Lot Number <br /> Q3 a51 f:kft( -e Cl Od-IL ' 5 <br /> Zip Code Phone Numbcr Subdivision Namc or CSM umt,<r <br /> LAKFIviLL-r. rY)r% 55d�`{ t 95z )e441-.28?s Li Sia P,nq_ <br /> I I T)pe of Building: ❑City ----- <br /> 1Z ' FdmJy Dwelling-No.of Bedrooms: 113 ❑Village <br /> _jbl, <br /> Puc Cm <br /> omercial(describe used:. Frown o t <br /> J )late-owned <br /> H[I Tvpe of Permit: (Check only one box on line A. Check box online B if applicable) Nearest Rnad <br /> �'t At.m�R Lanz <br /> v 7N' wSystem 2. El Replacement 3. ❑Replacement of 4. ❑Addition to Parcel TaxNumbet(�) t7 <br /> System Tank Only Existin S stem <br /> B I Permit Nutnber Date issued -� <br /> ... � <br /> Sanitary Permit was previouslyissued <br /> I\ ” Tvpe of POWT System:(Check all that apply) <br /> Zion-Oressunzed In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> = Prns ized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> C .-\t-trade ❑Aerobic Treatment Unit O Recirculating ❑Other: <br /> \ Dis crsal/Trcattr;cn:Arra <br /> --,r im, gpd, 2.DispersalArea 3.Dispersal Area 4.Soil Application, 5.Percolation Rate 6.System F:Ievm am <br /> Required Proposed Rate(Gals./day/sq.tt.) (Min./inch) Elc caw ur <br /> 45e) 375 3Fs'5, I. 2 Morpk g$.D yqi,o <br /> \'I Tank Capacity in Total #of Manufacturer Prefab Site Stec! I Pibcr 1'I:.r <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> NewExisting trete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ <br /> STtJ Aloc-S l000 l000 i 3KAu� <br /> VII Responsibility" <br /> I.the undersigned.assume res onsibili for in allation of POWTS shown o trached plans. <br /> PlUrt r ''amc I tint) PI bees nature(no ps): o. Business Phone Nwnbcr <br /> 418K S�PTIC & EXCAj <br /> r �ayS'7F <br /> s --- <br /> SPMNER, WI 54801 <br /> \ill Counq/ e r rel <br /> u DisapprovedSanitary Pcrmt ce(Includes Groundwater Date Issued 133Agent Sig nature I- ,i..... <br /> nprus :1Owner Given Initial Adverse SurchargeFj c /2/Z?,/ot <br /> Detemunation !/1 <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> CI OEC <br /> <UN <br /> B(JRNE� <br /> /NG <br />