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201 W.Warhngtoa Ave..P.O.Box 7162VConQfI/ <br /> a%n Maffito4 WI 53701-7162 Smilary Permit NmOW(to be flkd in by Co.) <br /> De artment of Commerce (6DB)2663151 4-712x?C) <br /> Sanitary Permit Application seer Plan LD.Number <br /> in err er I with Comm 83.11.,fes.Ada.Cade,pasta+mfmmOM Tan Provide <br /> may be used for secondary purposes Privacy Law.s15.04(lxsa Project Address Cif d'erermt dm mailing address) <br /> 1. AppGntiao b%rmatiae-Please P. AN <br /> �� .✓ <br /> Property Owner's Na i Parma d Lot d krck d <br /> Property Owner's M ailing Address Property I.aotios <br /> SW 'A.AflAr li.Section 11 Q <br /> City.Sate Zip Code Phone Number <br /> N S,YjW/ 71r—475--OW 9 (circle <br /> II. of (d W&all oat apply) T�_N: RT E ot�Y <br /> ah or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name CSM Number <br /> ❑PuNic/Commercial-Describe Use MW AVI/AYRV 't <br /> ❑Stere Owned-Desmle Use - .._. _-. ._ - ❑City❑Village Q1`owv d p of <br /> da <br /> III.Type of Permit: (Cheek a*ora box an toe A. Cmplebe ime B V applicable) <br /> A. c"..,Sy u. ❑ Rq*mmm Sys m ❑Trmmem/AWdbig Tank Replacement Only 0 other Modification to Existing System <br /> B. ❑Perms Renewal O Permit Rarisim ❑(Lange of 0 Perms Traced.a New Iia F1et1p s Perms Number and Dale Issued <br /> Before Expiration Plumber Owner <br /> IV,TnM of POW TS • (Check all that Wply) S <br /> ErNm-Aaaosd b4mund 0 Mound>TA in.ofsmouble.0 Mound<2t io.of sairabk and 0 AW3rade 0 Single Pont Sud Filter <br /> 0 Constructed Wetland ❑ Pressurized hWmmd 0 Noldag Tank ❑Pot Fiber 0 Aerobia Tkouaunt unit ❑Recuertl m g Sad Film, <br /> ❑Recirculating Symhaie Meda Fib. FrLachmg Chamber O Drip 1Aa ❑Govdka Film O neer(esplam) <br /> V. t Area Infamatioo: 8 <br /> Design Flow(bpd) Desip Sall An6ca oo R "1 Area spmsal m Required(sQ DArm Proposed(sl) sysElevatim C�47 <br /> yif•5 7 If. I ore4 <br /> VI.Tank Info Capacity in I Total Number blanufacoma Prefab Sae Sled Feer I Plastic <br /> CnOast Calbm OfUnis Coster Casstruaed Glass <br /> New F'atdag /✓ �� .!e ably' f7rLJJFjC . <br /> Tacks Tad¢ <br /> Seek or _ <br /> v <br /> Aerobic Treatment Unit asmae <br /> Dmsr Chwnher 0 - <br /> VII.Respooaboy Statnemmt-L tta-m8astllged,name amity far mgdatina of the POw n sows m the attached plans. <br /> PlwnWs Na me(Prim) Plamb.'s Si gors � <br /> e YbeRS Number B Siam Phone Number .. <br /> FOW41 r ittmbing 9lo <br /> Pbmmh�vgIV 2;p Cade) lis-63s= -57-2,0`4 -40x <br /> Spooner, WI 54801 Lai- vA- ob <br /> Ing- <br /> Approved 0 Disapproved Sorry Permit pee(includes Groundwater Dae food Iseaotg Sates) <br /> ❑owner Given Pn for Dermal <br /> Surcharp�) �ll(,5f. IZ-)&-0� <br /> IX.CosnUtioss of App wA UBtamns Aw Disapproval �/ <br /> *5" Eeowti<� A5 .4tVLw �v2 ks TD �EEQ. 64apaad fes 97. IL7 <br /> Asach==Pkm plmr(a ee Oraay only)for the sI un pay.rot lea 111101 SMx 11 laches in sift <br />