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I Safety& Buildin f>Dicuini <br /> NN L01 W. Wasluntpon .nv <br /> ` - Sanitary Permit Appl�ca±i-n <br /> In accord with Comm 83.21,Wis.Adm. Code I,(' <br /> (on,o,nrcc Personal information you provide may be used for secondary purposes (Submit completed for to c,uuuc it not <br /> [Privacy Law,s. 15.04(1)(m)] <br /> Attach complete plans(to the eoun coU c:�;.`;,r - — --- -------• ;;,;;; 1/2 x ;; inches in size. <br /> `� ���✓` Slate Sanitary a 't ❑C �'}fre ' ion to previou appli.a1;z, Sta:c Ptan 1,D.Number <br /> ,$µ�nei4 <br /> 1. Application Information_f case Print all n nr nrt..r. <br /> Location: <br /> i„nrr Name - Property Location <br /> n/S 70jerL4Z 1/4 1/4.S/? I d10 : A,/,rO <br /> m,Mailing Address Lol Nmnher <br /> d�O�O adi erL. _ LAnE 7- <br /> Zip <br /> Zip Code Phone Number Subdivision Name or CSM:N 1111 w i <br /> SSoV'i -Pq /9l <br /> 11 l>'P i o FdBinil aDwelling No.of Bedrooms: O Village <br /> u -�- <br /> J .— <br /> J Public Commercial(describe uscl: fownot <br /> J Ntate-owned <br /> Ill Type of Permit: (Check only one box on line A. Check box on line B if applicable) Ne a est Rnad _ <br /> 33S DNE N <br /> vtiesa System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to <br /> S stem Tank Only Existing System 102 —y) - Oy LOQ <br /> B I Permit Number Datc Issued <br /> Janitary Permit was previously issued <br /> 11 Type of POWT System:(Check all that apply) <br /> -><Noc-oressunzed In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> = Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Lute <br /> At-wade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> t Dis>crsahTrcatn:cn: Arc:; Sn:�.....,:i..... <br /> 11,11, gpdi 2.Dispersal,4rea 3.Dispersal Area 4.Soil Application, 5.Percolation Rate (.Svstem F.Icvalion <br /> Required Proposed Rate(Gals./day/sq.11.) (Min./inch) F.Iccai nir <br /> a00 day 7 �o� .ti 4s.i ' y7.�� <br /> V'1 -rank Capacity in Total of Manufacturer Prefab Site Stec! I FtNur Pls­ <br /> Information I Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> ST Atop/Z 00 DO / � � <br /> ?.A be ❑ ❑ ❑ ❑ <br /> II Responsibiliry Sta11-i-1-1a: <br /> he under t e sot <br /> % forlihasiallatiory6f the POWTS shown o ttached plans. <br /> P'n Signature no stamps): o. Business Phone Number <br /> N6228 COUNTY LINE R �y� <br /> y, e) ---- <br /> 715-635-7482 <br /> \I Il County/Department Use Only <br /> ❑ Disapproved Sanitary Venni Fee(Includm Gron;watcr Date IFFsued Issuing A+en igna re i <br /> �r ;u,.c ❑Owner Given Initial Adverse Surcharge]F c `,j('/l � /h P <br /> f Detertmnahon / z <br /> I X. Conditions of Approval/Reasons for Ltsappruval: <br /> I �r� <br /> Jul <br /> BURN <br /> k, 7ONN�UNTy <br />