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Safety and lrmldmgs Division county <br /> Als- consin <br /> „ 201 W. Washington Ave.,P.O. Box 7162 Madison, W1 53707-7162 Site Address LA <br /> Department of Commerce r Lw ,� _ _ <br /> Sanitary Permit Application Sanitary Permit Number <br /> '>—�t� <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision Ri <br /> �?Q G� ? <br /> ma be used for second purposes PrivacyLaw,s15. 1 m (l J V <br /> I. Application Information-Please Print All Information a- State Plan I.D.Number <br /> Property Owner's Name Parcel Number J`Y <br /> o" 6 ep_ Ola}-ZZ0 -OS 200 <br /> Property Owner's Mailing Address Property Location <br /> 21((0)3 *n MAik.S14 14,01b A u:s Td8 N,RISaA); <br /> City,Suite FLtp Code Phone Number Lot Number Block:lumber <br /> q :I141Subdivision NameCSM Numbe <br /> IrAJ12 3ef4'- 3 <br /> II.Type of Building(cheek all that apply) ❑City <br /> 01 or 2 Family Dwelling-Number of Bedrooms 2.. ❑Village — <br /> ❑Public/Commercial-Describe Use 2'rownship LA <br /> O <br /> ❑State Owned Nearer`(Road r <br /> -SQ-70 .Sor d ,OT r�OSf►y <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternal use). Complete line B if applicabk) <br /> A- I New 2 ❑ Replacement System 3 ❑ Replacement of6 10Addition to For County use <br /> System Tank OnlyExistio System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dare Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44/Non-Pressurized In-Ground 2111 Mound 47❑ SaM Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other 1 <br /> V.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Sail Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Ra1e(GaIs./Days/Sq.Ft.) (,MIn.Ancb) Elevation <br /> 300 452. Lf So 7 mor i, 92.1 45,I <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sieel Fiber -7—Ph.itie <br /> Gallons Galloas of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or HQU"Zvie I <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the tmdersigned tame responsibility for installation of the POWTS shown on the attached ph,as. <br /> tgbe llvn�l(_ r ) Plu is Si re MP=S Numxr Business Phon:Number <br /> � <br /> K EF7 C EXCAVA00 <br /> a�s-ry <br /> e ode <br /> SPOONER, WI 54801 �Ooe <br /> VIII. C layse Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dam Issued Issuing a igmmre tan ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse zh' �CO '�9' v <br /> Determination �Lf ✓ <br /> IX. Conditions of Approval(Reasons for Disapproval <br /> Attach complete planta(no the County only)for the system on paper not teas than 31/2%11 inches in size <br /> SBD-6398 (R. 05/01) <br />