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Safety&Buildings Division <br /> 201 W.Washington.Ave. <br /> —7 <br /> Sanitary Permit ApplHcat!^^_ PU Box 002 <br /> In accord with Comm 83.2 1,Wis.Adm. Code Madison.`A1 51707-7302 <br /> Personal information you provide may be used for secondary purposes <br /> camnnerce Y P Y (Submit completed}iron to county n not <br /> [Privacy Law,s.15.04(1)(m)] scare owned.) <br /> Attach complete plans to the coup co- _ -:__,_= =- �" ' " x 1, inches n size. <br /> Count. State Sanitary Perrrytgbee ❑V Yckifrgyis%to previous �li.ati�. State P:an I.D.Numbcr fly <br /> I.Application Information-Please Print all Infr"=tinn Location: <br /> Propeny Owner Name 111 SeoT(US� Property Locaon <br /> zZ 34NItl' I N�erSev. F6U t ✓rei`no'v1/4 SuJa.sT . _ <br /> Property Owner's Mailing Address Lot Number Bhxxk Number <br /> 2.067 �t its iZoad. -- <br /> C m.Sistc Zip Code Phone Number Subdivision Name or CSM Numkxr <br /> o nee LA_� 5qgo l ) 6:5 b33b o City <br /> II Type of Building: ❑Village <br /> X I or 2 Family Dwelling-No.ofBedrooms:%_ JdTownof�7 <br /> C-1 Public/Commercial(describe usel:• f�V-SK <br /> CI State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Near ar Road <br /> AL <br /> L) <br /> I <br /> ED New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax umberjs) <br /> S stem Tank Ont ExistingS stem � -5 <br /> — a <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> Iv.,Type of POWT System:(Check all that apply) <br /> y� Non-pressurized In-ground ❑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/Treatment Arca......•.a:: ... <br /> i irsi8m Flow(gpd) 2.DispersaLArea 3.Dispersal Area 4.$oil Application, 5.Percolation Rate iel. Elevation 7.Final Gmdc <br /> Required Proposed Rate(Gals./day/sq.tl.) (Min./inch) F,Icvnuon <br /> �c7D ¢143 (,d .7 Moi 1-t $�I.3 r l l•Io ¢.. .. <br /> V I Tank Capacity in Total #of Manufacturer Prefab Site Steel Fibr I PL s"' I I <br /> Gallons Gallons Tanks Con- Con- glass <br /> Information <br /> New Existing crete strutted <br /> Tanks I Tanks <br /> s C 7$O 750 1 (Jtes ❑ Q ❑ ❑ <br /> 3ZO 3Z.0 I ':PKi9LJ <br /> VIIRs o t •• A�� <br /> I t M�mstallation the POWTS shown on the attached plans- <br /> *a UN ignature stamps): o. Business Phone Number <br /> SPOONER, WI 5 aa4{g79 <br /> Plumbers Address 7wbw Code) <br /> VIII CountyfDepartment Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Iss_vumpy�-0.'ggent Signature(No cramps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) ^-� q /�j <br /> Detemrination OOLLIIJJIIJJ [0 -^x- <br /> Ix. onditions of Approval/Reasons for msapproval: <br /> SBD-6398 R(A/ur) <br />