236-168-00-1300-SAN-2010-163commerce.wi.gov
t1g.n.nt
Safety and Buildings Division
201 W. Washington Ave., P.O. Box 7162
Cuumy--
iconsin
Madison, W153707-7162
U
Snnimry PermtN rieR flkd in by Cu)
of Commerce
CST 10-130
534475
Sanitary Permit Application
Sate Transa,mn Nmdcr
In —man— wish I. Co.. 83.21(2), Wu. Man. Cale, submission of dais form or she allopp .a
govemmcnml unit is Ics,m ad prim m daaidng a eanimry pends. Ndc: Appian.. forms for Oca,.v and
POWfS are submatJ to she Dep scent of Camm n e. personal information you ouvWc may Its used far
peuleet Add. (ift iffixem don mailing udrao)
O.00dayy in records. with the Privac Law, c."ryl1 m, Sou.
I. A Iica[sort 111 ralydi.- Please Print All lnformadoa
Pmpeny Owncr'a Nemc
Parcel p
TOS A-t% (Joshua & Jessica)
'134, JIeB 00 _
Properlyne charter's Malin Address
Ra,\ +4w
Pmpeny Lomuon
Iqo N i - rl PA.
Govt.Us
S.fl.n �-7
Ciry, Side
Zip Cale Phone
Number
r t.JZ
S g{3
%!r — y0 2�
—'A._'A,
T-!' /_ N; R�cir<Iems)
If. T> building
b (chick all that apply) Lot
Is
Pi m 2 Family Duelling - Number of Bealrooms 3
13
5u1odiviston Namc
Gluck@
alp- ESY6FC5
❑ PublidCommcrcial - Deuribe U.
❑ City of
❑ Sore Owned - Desvibe Use CSM
❑ Village of
Number
Mown of—
O
111. Type of Permib (Check only one Lox on Ilve A. Complete line
H If applicable)
TAL]ewS stemY
WReplaeemem System
❑TrtnmeWHdding Tank Replacement Only
❑Oter Modiricadan to Bnoing Sysmm(explain)
rmit Renewal
❑ Permit Revision
❑ Change of
❑ Permif Transfer to New
Lou Previous Permit Number and Dam Lamed
e Expiratlon
Plumber
Owner
OpT'!—`Q6/ GhS/f-if
IV.
Tyrse of PO WTS S dear/Cons nent/Device: Check all thel a 1)
Phim-Pressurized InGramd ❑ Prueurircd In-Graua d ❑ AlGmde ❑ Mound a 24 in. of mimbie soil ❑ MaaM 1 24 is. of suitable sail
❑ Holding Tank ❑ Odor Dispersal Component (explain) ❑ Prcrremmem Device (explain)
V. Dis ersallrroalment Area information:
Design Flow, (gN) Design Sail Application Rate(WAsp
Dispersd Area Required (eo
Dispend Area Proposed (so
System Elevdion
Vl. Istak Info Capacity to
Tend
pof
Mdmfa,ucer
9
8
Get].
New Taub naiWng TaNa
Get..
f
5mtie.neHaYMgTank 1000
1
(000
1
Smu"-dt
Dams anmber
VII. Res onsibllily 8(atement- 1, the onderdgved, ascom rapmoiLnity for hnlalladpn of the POWTB shows an the dmched plans.
Plumber'¢Nome (Prim) plumber's Sigmmrc Mp�umher Business Phone Numbe
`
ITu OY Add.( Stred�CitY. Safe, Zjp`eF:/aa�-
) W X � TQ 2- 1,
eaOrlment
VUI. Count /De Use oill`I'
(Approved/
Disapproved
permit Fee
Da¢Issued
Issuin; Agent Signamrc
zz❑
CO. Given Reasunfar Dedd
'300.00
8/17/10
IX. Conditions of AppmvaDReuons for Disapproval
IMPORTANT NOTICE: Wisconsin State-Statut4 C114ter 145.245
(3), states you are required to have your septic tank
pumped/inspected at least once every 3 years.
SBD-6398 (R. 02/09) Valid thm 02111
Reccivca: b/13/10 :'J..... I" Ou /1410 -a SAWYER COUNIV Loning; P:,pe t
1 1 1 1•
1 11 11
Olr¢e of
Sawyer County Zoning Administration n�
P.O Box 676
Hayward Wisconsin54843
iER ,CO tl (715)634.8288
FAX (715)638.3277
i wi w Yt0`�VID \,10
�a e� Toll Frce CourlEomdC nl lnrormntlon 5-0A-099-U1p U`,i�
SAWYER COUNTY SANITATION DEPARTMENT
TEMPORARY EMERGENCY TANK INSTALLATION APPROVAL
PROPERTY OWNERS NAME: SOsS tj f V W o rj-�
T
TOWN OF: "1 W OIVJ
ADDRESS: tj 10 [oy►J' 12atr�c�e'
I, _ 0t-w �J1c'�' r&k`S�w , a Wisconsin
Licensed Plumber, do hereby acknowledge that I am receiving temporary approval to
install a septic tank/holding tank without a soil and site evaluation, or existing system
evaluation, and private sewage system plan review due to inclement weather and/or
health and/or safety emergency.
Further, I acknowledge that a soil and site evaluation, or existing system evaluation, and
private sewage system plan review will be conducted by the deadline stipulated by the
permit issuing agent, or as soon as weather conditions or circumstances permit. If the
private sewage system is found to be failing as defined in s. COMM 81.01 (92), Wisc.
Adm. Code, corrective measures will be taken as such that the private sewage system
complies with all applicable requirements of chapter COMM. 83, W is. Adm. Code,
within 90 days of this agreement.
I further acknowledge that failure to comply by obtaining all necessary permits after the
deadline date may result in the issuing of a citation, under Section 11.3 [2) Sanitary
Permits], of the Sawyer County Citation Ordinance.
DEADLINE FORTHO AGREEMENT SHALL BE: dh 7 b 0
Signed: IM I/Y/
Date: Y IW I
Accepted by: 7�s In.�oQY
Date of temporary emergency approval: DoA3 A C)
TnrAT. a.nm
INDEX SHEET FOR POWTS
PROJECT NAME _t'T��[c�nr't'ln 'Il C S�IS� t NO. IZSzfr
OWNER Vns�n ttev 1 n
ADDRESS: I dt o
c�J
PHONE: CIS- 434�
PROJECT ADDRESS: — s�-e —
LEGAL DESCRIPTION: Lor f3. Est.als Ss.b,
Sang � �, 2gw�
saw —
PARCEL.. NUMBER: Z3&-(j:g, o -13ao
I. INDEX SHEET
?. PLOT PLAN
3. SEPTIC TANK CROSS-SECTION
4. CELL LAYOUT & CROSS-SECTION
5. SOIL EVALUATION
6. SOIL TESTER PLO'C PLAN
7. SYSTEM ELEV. VERIFICATION FORM
8. SEPTIC SYSTEM MANAGEMENT PLAN
PLUMBER'S SIGNATURE ,�,,,,.,,,,.__ MP # 22(S'1 1p
DATE: d i ut o
POWTS COMPONENT MANUAL # (U 7 05"-O
r
N
d BM SE (0104 /J R"K9ty- s-t- Rc�
3 48.79 s z1 -r- 41 2 oG k1
al9sewer-�a hooK�� 9�.2.4' P�� 236-1b�-00 _ 1300
flew S.T. ih 96 sw ou' 9 (6.7$
.-7 So. IV fec.: s s+. etW - q4 •S.'
Afi
Shed I scale I ` = 30
i level s:i'e, >�o Co,44ovf
qar
Y. (c/o. (olo ` cat"
vJA �� 3 6 a Rumu ben W/ d2w cy- Lp S C3�)
E rat. >`x OYedtGO S IOW ^I
CO. flew
':
3
98.19.
ele,3J A P(4Lt (muse
SEPTIC TANK C.'.OSS S?�-T=%Pi ?,IND S_ 01F A7
4" PYC INSP. P=D % ° MIN. A30VE GR--'.D-7 WHEN INLET
MANHOLE IS BURIED A MAXIMUM OF 6" BELOW GRADE.
TNTSH-rD GR.ADr-
7NL_i
APPROVED
PIPE 3'
ONTO SOLID
SOIL
SEPTIC
TANK MAWFAC3URER
TANK SIZES!
NOTES:
SUTIC
3" A?J30V-L—D, NG
UNDER TANK
SPEC=--C —IONS
�S v►tiU SSA
4" MINIMUM
ABOVE GRADE
OUTLET PIPE
APPROVED
MANHOLE Covgp
W / PAD LOC K F
WARNING LABEL
3/8
INFILTRATOR CHAMBER CROSS-SECTION
3'
oG CELL(S)
02
3' X &&.Io&'
CELLS WITH
14o QUICK 4 CHAMBERS b Z END CAPS
31
CHAMBERS AT
20 SQ. FT. =
��� SQ. FT.
�.
SETS OF END
CAPS @ 5.8 =
SQ. FT: TOTAL SO. FT . =b._I- 4
4"
APPROVED VENT
CAP OR INSPECTION CAP/ PLUG
4 '• SCH 4
PVC PIPE!4 I FINAL GRAD-7 19.7v 4ve-
�� 1: is !i/ I// /�1�/i . ♦//�
•
T � I' •` �
Schematic of
Single -Layer
System
USING I14FILTRATOR
QUICK 4 STANDARD
CHAMBERS
H•20
Intiftnict C`=_-cn
r
SYSTEli ELEV.9�,3!
PAGE 4 OF S
— pol"4e.i,- 6f.-I
wjsocnstn Department of Commerce SOIL EVALUATION REPORT
Division of Safety and Buildings
In acwtdance with Comm 85, Ws. Adm. Code
Attach complete site plan on paper not less than 812 x 11 Inches in size. Wan must minty SQ L%I%
indude. but not Bridled to. vertical and horizontal reference point (BM). dUlaction and Parcel I.D.
pement slam scale or dimensions, north arrow. and location and disWce to nearest road.
Ceti TIS- SM1S80 Please pdnt all lnfbnna!lon. Reviewed by
Pafaorrat � you pravkte may be used for arseondary►pu�Oses �rlvaey taw. a tsoa (t) (fn)).
Page of
00 -13oo
DaW
Property owner �t JJ Property Location
TQS F. ' �C ss tom. L.. tZ w.)o PT17 GovL Lot 114 114 S 27 T 141 N R OQ E (or) i r�
Property Owner's Maft Address Lot # Btodc # Subd. Name or CSt#
loco 4 nl Qat1 •e•- sf . Road 13 l a et.- E%16ies Got- 13
City state • Code Phonemm.w Qgty ❑ vBia$e ❑ Tam Nearest Road
I tF&MW&rd .1 W ( I S'48YJ I (Tr ) 43'f - CIotq I HCw corn 1 �jfx.rtgrrSf'. ��
❑ New COmbuftn Use: Cg' Residenliat I Number of bedrooms.._ Code dertved design Sow rate 'fSO GPD
t ❑ Public or commercial - Describe:
Parent material a to C 4 i �- [ Food Plain elevation if appicame _ Al 4 it,
cement oarun s .? S o l 15 1`�e O t OK-f K d ed S y s . M-1 e e CH -.. 9 Y.S • _
arM
(Mcik rtxh9 c 93.62 - 4 Y•S`)
UBodno
# V ocAUIV
S ,T- [k Pit
Ground surface elev. S • ?4 ft.
of
Depth to (lmdtt fader 105 in.
Hortwn
Depth
Domkgffd
Cotor
Redox Desaiplim
Texture
Struclute
C mislence
Bound
Munsell
OIL Sz. Cont. Color
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CST Name (Please Print) - - Stgnatare CST Number
10 913,qij SMZ.
L,t�.J LZ( Vf 43
g _ 1Y--10 -Z(S-634-8-)19
SBn-833o
Property Owner ` , ey wo r+ Li Parcel ID #
Bodm # - ❑ Boring a
pit Ground surface elev. 4 9 •? q R Depi to wing factor in.
Horizon
Depth
in.
Dominard Color
Munson
Redm DesaWm
OU. Sz Cont. Color
Texture
Structure
Gr. SL Sh.
Coralsteim
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F # ❑ Saft
❑ ptr Gmurd surface dev.
t:. Depth to ftffng fader
f•iaimon
Depth
in.
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Munson
Becton Description
Qu. Sz. Cont Color
Texture
SEructroe
Gr. Sz Sh.
Consistence
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# ❑Bortng
❑ Pit Ground surface etev. 1L Depth to ingft factor ln.
• BRUNd#1= SODs> 30 4220 a*& and TW >30 < 150 nv& •Eftent#2 = BODs< 30 nViL and TSS <30 ajWL
The Depabnent of Cow is an equal opportrmity service provider and employer. If you need assistaaca to access se,i. or
need material in an alternate fomuat, please contact the departinmt at 60&-26&3151 or 1TY 608-2644T77.
o when 3cs E{eyws c '
A 1- 100 TOP 0Co'tKer 4 u'►c�evS�.
N a
yWaod 4-k�t5 Lo4 l3
5 2Z 'r 41 2 oq UJ
r 31g. _ @.�ooK�p 9'7.Z4' : _ P11J 236—i69.»00 — 1300
S4Wtr
N � _r
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i... ••• : , ?„ s...: _ she _ . Scab t 30
tevcl S:{'t� L?c c"4ovGS {
b
oil 36d y
14
Fx Atw `I'I
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it
�sr z2�E Qo �
_
Owner: T-1"e Li d
Sys(. Elev 411t — 9 t•1' -.S Ce�ar�nw►e� c�.edl
B cl. B el.
syst. --- _ - --- ----
as-- s ---•
_ _--1-- -7 �eCO a�Me -- - 11 p�
t( q a ct t
A-1
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16S $.-75=90 ,Zl
CST:- M 0� k<- I ,
S yst. Range 3 bZ" to Ci4, � r � l aX
Ld. Rate
B cl.
9b--
---- �x Ca:1e
r18 = ?.,I = at 0 . to Z.
POINTS OWNER'S MANUAL & MANAGEMENT PLAN
FILE INFORMATION
Owner 7bsk Wp
Permit #
DESIGN PARAMETpon
Numberof Bedrooms:
?J
p NA
Number of PublicFad'lity Units:
50NA
Estimated (average) Flow:
?7 �tj
(gatrday)
Design (peak) Flow ; (estimated x 1.5):
450
(gatiday)
In Situ Soil Appricalion Rate:
, •1
(gatfdaym')
Standard (Domestic) InfluenUEffluent
Monthly average
Fats. Oil b Grease (FOG)
Biochemical Oxygen Demand (BOD%)
s30 mg1L
s22111 mg1L
❑ 14A
Total Suspended Solids (TS5
s150 m n
High Strength Influent/Eff6ent
Monthly average
(FOG)
>30 mg1L
(BOCQ
>220 mq&
GbNA
(TSs)
>1511m fl.
Pretreated Eftluent
Monthly average
(BOD.)
s30mgrL
Feral Coliform { eamelrir ears}
slo,
DNA
Maximum Effluent Particle Size
)L in dia.
❑ 14A
Other.
19 NA
MAINTENANCE SCHEDULE
Service Event
Pump out contents of tangs}
Inspect condition of lank(s)
Inspect dispersal cell{s)
Clean effluent filter
Inspect pump, pump conbols li alarm
Flush laterals and presstne lest
Pope g of
Service Frequency
When combined sludge and scum equals one-third (9) of tank volume
When the high water alarm is activated
At least once every:
O month(s)
3 ® yearts) (Maximum 3 years)
❑ 14A
At least once every:
Oyear(s) (Maximum 3 years)
0 14A
At least once every:
❑ month(s)
3 121 yearts)
Q NA
At least once every:
❑ month(s)
❑ year(s)
IJA
At least once every:
O monih(s)
yearts)
NA
At least once every:
r-1 month(s)
D year(s)
Q'NA
ANA
MAINTENANCE tNSTRUtTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: 1,12ster
Plumber. Master Plumber Restricted Sewer, POWTS Inspector, POWTS Mainlainer, Seplage Servicing Operator (pumper). Tani
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or IeAs,
measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the around surface. The
dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent
on the ground surface. The ponding of effluent on, the ground surface may indicate a failing condition and reouires she immediate
notification of the local regulatory authority.
When the combined adarrnulalion of sludge and scum in any treatment tank equals one-third (k-) or more or the tart volume, the enti!e
contents of the lank shaft be removed by a Seplage Servicing Operator and disposed of in accordance with chapter NR 113. Wisconsin
Administrative Code.
All other services, inclutling but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment un�s,
and any servicing at intervals of s12 months, shall be performed by a certified POWTS Maintainer.
A service report shall beprovided to the local regulatory authority wilhin 30 days orcomplefion of any service event.
GIAW-D05 (02/04)
ARTYP AND OPERATION Fope of
'-or new construction. prior to use of the POWTS check treatment tanks) for the presence of painting products, solvents of other
:hemicals or sediment that may impede the Irealrnenl process and/or damage the soil dispersal cell(s). It high Concentrations are
Detected have the contents of the lank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During extended power outages pump tanks may fen above normal highwater levels. When power is restored the excess wastewater will
je discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent.
ro avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the
effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels
within the pump tank.
3o not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within
S feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the fife of the POWTS:
antibiotics; baby wipes; cigarette butts; condoms• cotton swabs; degreasers; dental floss: diapers; disinfectants; 1a1; foundation drain
(sump pump) discharge• fruit and vegetable peelings; gasoline; grease: herbicides: meat scraps: medications; oB: painting products;
pesticides: sanitary napkins: tampons; and water softener brine.
-,BANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly
and safely abandoned in compliance with chapter Comm 63.33. Wisconsin Administrative Code:
All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed
a The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing Operator.
After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
O A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by required
setbacks from existing and Proposed structure. lot lines and wells. Failure to protect the replacement area vwm result in the need
for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in
effect at the time or their permit issuance.
O A suitable replacement area is not available due to selback: and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort.
The site has not been evaluated to identify a suitable replacement area. Upon failure of the POHVTS a sob and site evaluation
must be performed to locate a suitable replacement area. It no replacement area is available a holding tank may be installed as a
last resort to replace the tailed POWTS.
D Mound and al -grade soil absorption systems may be reconstructed in plane follovring removal of the biomal EI the infiltmlive
surface. Reconstructions of such systems must comply with the rules in effect at that time.
'dAR1J1N G
TREATMENT TANKS AND HOLDING TANKS ?,PAY CONTAIN POISONOUS GASSES AND LACK SUFFICIE14T OXYGEN
r TO SUPPORT LIFE. 14EVER E14TER A .REAThiEt4T TANK OR HOLDING TANK UNDER t.l:l' CIRCUTASTAI4CE.
DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT.
DDITIONAL INSTRUCTIONS:
oQWTS 1 STALLER POWTS MAINTAINER
(dame CIS pName /A
Phone —j S—'� Cf 8 Phone
PTAGErSERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name 'i ra-c J +f L Name s'Ot�(.,
'here 1 tS- �{(02-3 i Si Phone -7�S . (,o3q — i,Z Yd'
,is document was dratted by the starts of One Green Lake. Marquette and VJaushwa County PO%hQS regulatory ;%oercies in comp&anm with cr*pler
.omm E3.22(2)(b)(t)(d)&(f) and 83.5A(t),(2) d (3). Wiscons;nAdminislraGve Code.
PRIVATE ONSITE WASTE TREATMENT
Nvisconsin SYSTEMS
Department of Commerce (POWTS)
Safety and Buildings Division INSPECTION REPORT
(ATTACH TO PERMIT)
GENERAL INFORMATION
Personal information you provide may be used for secondary purposes i Macy Law, S. u.u4 t r )tm
Penn€fit Holder's Name: �s ❑ City ElVillage ib! Town of:
✓06�%L rt, 4--3e5siCq He wamn
Insp BM Elev: BM Description:
(r `
56
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Qk-S C-A&
1000
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG
VENT To
AIR INTAKE
ROAD
Septic
.1g'
+50'
224
a.a'
NA
Dosing
NA
Aeration
NA
Holding
PUMP 1 SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
TDH Lift
Friction Loss
Sys Head
TDH Ft
Forcemain
L
I Dia
I Dist To Well
1k11 4*''f_1llt� 4441►17a]:1�,FAIIs] �
DIMENSIONS
W 3'
L 6 y
of Cells a
SETBACK
P ! L
BldgWell
]!OHWM
of Nay
INFORMATION
aters
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County
Sawyer
Sanitary Permit No:
10- 163
State Plan Transaction ID#:
Parcel Tax No:
P36-10-00- 1300
ELEVATION DATA
STATION
BS
HI
FS
ELEV
Benchmark
Y. S'Y
laY•S
100.011
Bldg. Sewer
7 3 '
17- 2 V
St/ Ht Inlet
7. G'
'
St / Ht Outlet
7,7(6 ►
b.`7 2'
Dt Inlet
Dt Bottom
Installation
Contour
Header / Man.
9 ?'
9S. 31
Dist. Pipe
Infiltrative
Surface
I o•Z3
iq3)
Final Grade
Type of System
Distribution Media
Manufacturer.
3�9(
.q Conv
o Aggregate
o IGP
M Chamber
Model Number.
o AG
o EZFlow
o Mound
o Other
Q
X Pressure Systems Only
Header! Manifold
Distribution Pipe(s)
X Hale Size
X Hole
Observation Pipes
Length Dia
Length Dia Spac
Spacing
10 Yes ❑ No
SOIL COVER
Depth Over Depth Over Depth of Seeded / Sodded Mulched
Cell Center Cell Edges I Topsoil 1 ❑ Yes ❑ No 1 ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
Plan revision required?❑ Yes ❑ No 03 0 a t( 6 g n f
Use other side for additional information Date POWTS Inspector's Signature Certification Number
Bureau of Field Operations, PO Box 7302, Madison, WI 53701-7302
SBD-6710 (R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: 10- l63
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