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Safety and Buildings DIVISIdn county <br /> 201 W. Washington Ave.,P.O. Box 7162 a <br /> isconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce QZLl-3110- 05 0 <br /> Sanitary Permit Application Sanitary permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision Qjl /2 <br /> may be used for secondses PrivacyLaw, 5. t (m <br /> I. Application Information-Please Print All Information Sate Plan I.D. Number <br /> Property Owner's Name Parcel Number, <br /> di.600EQ <br /> s -t Sc41eaA IITEK aid QS ;).b11L Access <br /> Property Owner's Mailing Address cation <br /> i Property Lo <br /> 13t] O C nJ '4 'F:S/o T <br /> City,Sure Zip Code Phone Number Lot Number Black Number <br /> L 4 Lo t L <br /> C Subdivision Name CSM Numbr <br /> ,Ue-L.L (ftw-L LJS 5g871 33oS VI 46 Lyth <br /> II.Type of Building(check all that apply) <br /> ❑City <br /> I or 2 Family Dwelling-Number of Bedrooms 3e <br /> ❑Villa8 _ <br /> ❑Public/Commercial-Describe Use ownship <br /> ❑Sum Owned Nearest Road <br /> III.TypeofPermit: (Check only one box online A (numbering scheme for.internal use). Complete line B if applicabl,c) <br /> A' IIA New 2 ❑ Replacement System 3 11 Replacement of 6 11 Addition to For County we <br /> S�stem Tank Only Existing System <br /> B. I ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44Non-pressurized In--FOqrou 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Fres rt0llnn--Grouund� 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dis ersal/Treatment Area Information: <br /> Design Row(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Mht.nnch) Elevation <br /> ' / i 87.S e- JW,0 <br /> �f ^70,- h :I. gg.f c 5 9i. f <br /> VI.Tank Info Capacity in Toui Number Manufacturer Prefab Site Sicel Fiber Pli,aic <br /> Gallons Gallons of Tanks Concrete Comtrucmd Glass <br /> New Faisnkosn, <br /> T. <br /> Ta <br /> Septic orljoldul Tmd- <br /> 000 <br /> Rosins Chamber <br /> VII. Responsibility Statement- I,the ersigned,assa responsibility for installation of the POWTS shown on the attached pints. <br /> M <br /> Pluprpe$fl�ao IitIr� & EXCAt!!� <br /> �Sigmmr Bus <br /> MP/MPRS Nund: iness Phori.Number <br /> _-.11110annPn-pups� 7 <br /> PIu n <br /> SPOONER, WI 54801 <br /> VII Count 1 <br /> Approved ❑ Disapproved Sanitary Perini ee(includes Groundwater Date Issued Issuing Signature o n PS) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determina I <br /> I7(. Conditions of Approval Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches In tree <br /> SBD-6398 (R. 05/01) <br />