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cYvxY <br /> Safety&Buildings Division <br /> 201W.Washington Avc, <br /> Sanitary Permit AppTHica±i Dir <br /> accord with Comm 83. , s. m. Code 15_F3oc /1u2 <br /> In 21Wis.AdCd <br /> ^ <br /> >,dadison.`,1r15i7U7='3(1_' <br /> nrIf*n-,.,,,* ..,domino ice Personal information you provide may be used for secondary purposes (Submit completed torn to county if not <br /> (Privacy Law,s. 15.04(1)(m)] state owned.) (U`l <br /> c. W <br /> Attach com lete tans to the coup co .,:: .- L :,� ____::c: __ : : 2 x I 1 inches it size. <br /> Couniv Stale Sanitary Permit N Chet i revisi to previous a y icat!" State Plan 1.D.Number <br /> me 3_ � o4a <br /> L Application Information- <br /> Please Print all Tnfnrmnrb.n Location: (� l <br /> Property Owner Name Property Location <br /> ARSB 5E 1/4 Sr= 1/4.S/D T40,\.R i?Oor <br /> PropertyOwner's Mailing Address Lot Number BloekSunilxr- <br /> 6-7y Pal. Covr{.. I <br /> Cln.vac an.vacLip Code - Phone Number Subdivision Name or CSM Nunhcr <br /> a' dcV" Lc SSloi7 . . ( -71 )JF4.160foal <br /> II Type of Building: ❑City <br /> X I or 2 Family Dwelling—No.of Bedrooms: ❑Village <br /> J Public/Commercial(describe used:. 12"1'ownof <br /> J State-owned SG'De <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road J <br /> �J3/i Kf.S NGC. <br /> A) 1. ❑New System 2. g Replacement 3. ❑Replacement of 4. ❑Addition to <br /> System Tank Only Existing S stem OZ 3 L O G <br /> B) Permit Number Date Issued <br /> 11.A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> iX Non-pressurized In-grouni i � ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V DIS ersal/Treatincnt Are$i illim maum. <br /> 1:7rsign Flow tgpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7, Final Gradc <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> aoo 4429 45yo . 7 "Wolf4OA qi.S X93.6 <br /> VI Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber I Plast". <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> 7S o �I�ArDL'o-rnb. <br /> '500 00 <br /> II Responsibility <br /> 1.the undersigned,assume responsibility for installation of OWTS shown on attached plans. <br /> Plumbers Name(print) Plumbers i a (nos s): No. Business Phone Number <br /> M&K SEF91C & EXC, ATION <br /> Plunbe 94M Am"MaD <br /> SPOONER, WI 54801 <br /> VIII CountyAMMIMZroy <br /> ❑Disapproved Sanitary P " Fee(Includes G dwater Date ssued Issuin eni Si amps <br /> ❑Approved ❑Owner Given Initial Adverse Surcharge F �7v /� <br /> Determination (l✓ / <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> i <br /> Far, <br /> 0 b <br /> �` ut 1 2001 <br /> SBD-1)398 Rwrut, Z, NG U1�7Y <br />