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Safety anti Buildings Division County <br /> WisconsinW-W"hJv91QaAvr.,P,0.B0X70&2Ol , 53707-7082 SiroAddras <br /> Department Of Commerce 2.8o13 CT 11,4 /1 <br /> Sanitary Permit Application Sanitary Pcrmit Number <br /> In accord with Comm 83.21,Wis.Adm.Cud@,paria W io{omayoo you provide <br /> roey be and IM secondary see prin IAW Q5.2g] m Check if R@vision <br /> I. Application Information-Please Print All Information <br /> L I� Stale Plan I.D.Wumber <br /> Ln <br /> Progeny Owvcr'a N(a`me / Parcel-Number ILtQ OQ V/GK �LI/'1>C'. <br /> Proper �I � <br /> Oz8- /z3 oz Soo v l <br /> Property Owner Mailing Address Property Location <br /> aJ v saJv.•S Z3 TqV N R /4f tj <br /> City.State Zip Code Phonc Number Lot Number Iock Number <br /> Subdivision Name CSM Number <br /> 5'r /J44.4_. r✓1n SSI/9 /esl-So/- oSBz <br /> H.Type of Bull 8,(Check all that apply.) <br /> 1 or 2 Family Dwelling_Numberof Bedrooms p Clty <br /> 0 PubWC--WcW-Describe Use OVillege <br /> 0 State Owned owmhi _ <br /> Nearest Rod <br /> Ill.Type of Permit: (Check only one box on Ike A..Namberlag 4 fo001tedwl use) (Comptek Nna B,itapp cable.) <br /> A. IO New 3 30 Replaceromt of 60 Addition to :. <br /> S stem y� Tank 0nlExisthi 3 For County am <br /> B' O Check if S!t�,ymit Ptevioualylhuued Permit Number ;Ie Date Inued <br /> IV.Type of POWT System: (Check all that apply..Numbering isfor luternW use). <br /> 444 Nm-Pressurized hrGrouod .2lo Mound 470 Scrod Filter 50E3 Conshwd Wedaud <br /> 220 Preauuired In.Ground 410 Holding Tank 480 Single Pass 51 O Drip Lire <br /> 450 At-Grade 460Acrobic Treatment Unit 490 Reciroonieg 3000ther <br /> V.Dia ersal/freatment Area Information: <br /> Design Flow(gpd) RD�ia W Ams Dispersal Ana Soil AppScation Percolation Rate S <br /> Rate(OWaID ,pt Yslem Elevation Final Grade <br /> ayt/S9 ) (MinAmb) Elevation <br /> to o O BSS 87S 17 1,-7,9 h go. b '� A 94/o' <br /> VI.Tank Info Capacity in. TOW Number Maoutuxuucr PmLb Site Stat Fiber Plastic <br /> Gallow Gall= of Taub Concrete Cxisttucted Glass <br /> Naw FiW g <br /> 7rmks Tanks ' <br /> Seale a,yloWeg-Tank. �'$.O /Z$�O oZ�q[a� <br /> Dosing Chamber <br /> VII.Respo to N d. a responsibility for loataWtion of the POWTS abouro on the attached p r <br /> MWEIEs MPIMPRSNumber BsninewNumber <br /> SFMNFI��VFiV46U1 9 " a7�id879 <br /> 0 Unapproved DW Iwnd le t S' o Stem e <br /> Z Approved Given lWeW A&C" Sanitary Pee(Wchwoa GNaodw P 1 <br /> 2 50 oc <br /> DG Conciltions of ApprovaUReuons for Disapproval <br /> M&K SEPTIC & C1ll/fiVH11UIVmc.awaatr,srtkasyMa�aap.pv.r th .61/2111lack"1..laa <br /> N6228 COUNTY LINE ROAD <br /> SPOONER, WI 54801 <br /> 715-635-7482 <br /> CRD-6398(R.05/01) <br />