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Vvis Safety sad Buildings DivisionFconsin 201 W,Washington Ave.,PA.Bex 7082 <br /> Madisoa,WI53707-7082 SiteAddnas <br /> De artment of Commerce p <br /> SanitaryYst <br /> Permit Application Petmt Numbs <br /> In accord With Comm 53.21.Wu.Adm,Code.persona information you provide _ <br /> ma be need tot wenn ws Prive Law I5. 1 m Check if Revision 7 ' 1� <br /> 1. Appticatlon lnfornutlon-Please print All Informatlon t U <br /> Shte Plan I.D.Numbs ^ <br /> 'Proprny Owna's Name <br /> Parcel Number ( (� <br /> /sfE �Jr V <br /> P-Pcrty Owna'a Mailing Address GIS✓ GZa/_3//O- Os 00 <br /> aS/a3 ,J�f-'( ProPenY Location Vt£C.l7r�o <br /> �✓e AfJ <br /> City,State Zip Code Plnne Numbec y '/:S /O T N R / <br /> Lot Ntrmhm I Block Number <br /> Subdpvision Name CSM Number <br /> csr�es r12 /97n 5590/ <br /> ll.Type of BuBding(Check all tbat a 1 . /`�Z`� <br /> ClI or 2 Family Dwelling-Number of Bedroomsp ) <br /> ❑Ciry. <br /> ❑ PublStaw Owned pal-Describe Use Vii e <br /> ❑ State Owned BS _ <br /> Townahi <br /> Nearaat Road <br /> IIL Type of Permit: (Check only one box oa UPC A.,Numbering V for tpternal use.)A. New <br /> sm � (Cotop4te Ilne B, appBcab4.) <br /> nem 203 Rep�a =Syttof ❑Addion <br /> Tank Enestem <br /> - ger County uss <br /> B. <br /> p Check if Sanitary Permit Previously Issued Permit Number - .. <br /> I Date Issued <br /> IV.Type of Pow 1 System: (Check all that apply. Numbering V for Internal user <br /> 22. Non gess d IgG=0 .2'0 <br /> 2t❑Mound 47 ) <br /> J r ��F ❑ Ser Filter 50❑Constructed Weiland <br /> 450 Pt-Gr d, d r �� 410 Holding Tank 48 <br /> C) Single Pau 51[3 Drip Lina <br /> 45❑At-0rade 46❑Aerobic Treatment Unit 49❑Rwuculatmg 30 Other <br /> V.Dis ersaVrreatment Area Information: ❑ <br /> Design Flow(gpd) DUPM14 Area Dispwasl Area Soil Application PermLd <br /> Required Propped Rate(GilsJDrya/Sq.Ft) in h)on Rata System Elevation Final Grade <br /> Elevation <br /> 300 5032- �So <br /> VI.Tank Info Capacity 4„ row NumbeNumber • -7 mor � s S/.z a Sz.0 >967.0 <br /> GWom Galloon r Maonfactlner ProSb Site Steel Fiber Plastic <br /> Neal Etisuog ConcreteCaostmckd Goss <br /> $f'lIC f(MnlAine T..L Tank, T4 . <br /> 800 800 <br /> Doting Chamber <br /> VII.Responsibility Statement-L,the enlgned,assume a PondbWty for Ins41ktlon of the POWTS shown on the attached pima. <br /> Plumbees Name(Print) P SWAMM, <br /> M&K SEPTIC & LAC "'P"'PR=N mbarp Bm ness Phone" tuber <br /> Plum O 7S <br /> SPOONER, WI 54801 <br /> VIII.Court e I <br /> / ❑ Disapproved <br /> V Approved Q OwnerGiven Initial Adverse Sanitary Permit Fee(includes Groundwaur. Date Issued in S' o Stamps) <br /> Detemrinatlon Surcharge Fee) � -a!O u9 /AA <br /> OG � <br /> IK Conditions ofppproval/Reasons for Disapproval <br /> Mteea eompkk pkat(re ke Couury talyj br lae tyrlem eo paper ab km W a 81/3 a l l keno k alae <br /> S R r)-6398(R. 05/01) <br />