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__T <br /> Safety& Buildings Division <br /> Sanitary Permit App!lFatlen 201 W.Washington,At-e <br /> -— In accord with Comm 83.21,Wis.Adm. Code Box su. <br /> .• � ��- � � <:omrnarce Personal information you provide may be used for secondary purposes ^.adson. X, i','; � „t <br /> [Privacy Law,s.15.04(1)(m)) (Submit completed form to county it not <br /> Attach com le[e tans to the coon co--' <br /> I I inches in size. <br /> $tgte Sanitary Pemut Number Check i£g�ision to revious (� <br /> ,E7WL►aQ.LI. (- �f p ppli�60:, State P(ca I.D.bomber <br /> I. A lication Informati,n- Please tint all Information a` Vl <br /> ., a„net yame Location: _--.- <br /> Property Locanon v` <br /> Vatimg Address <br /> 1/4A/UJi4.S3�2_4/0 <br /> �,u�r,-• Lot Nwnber <br /> Z-7 s4 q C�t..t. ?d q A4” <br /> Lip Code Phone Number Subdivision Name or CSM <br /> o0ner �JZ S4 2101 i > 96 <br /> II Tcpc of Building: ❑City <br /> J - ' rainih Dwelling—No.of Bedrooms: ❑Village <br /> Commercial(describe usc4:•. '46'fow11of <br /> J �tatc-owned <br /> I[I Tvpe of Permit (Check only one box on line A. Check box on line B if applicable) Neill' Road — -- <br /> s I n New SystemB n /Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Numbet(h) <br /> I System Tank Only Existir S stem OAS-y 13J -Q 1-70 U <br /> I Permit Nwnber Date Issued _ <br /> A Sanitary Permit was previouslyissued <br /> 11 . Tv pc of POWT System:(Check all that apply) <br /> /Non-pressunzed In-ground f{I_C.RpS ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> _ Pressunzed In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> r At-c adc ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> Dispersal/Treatment.Arcs <br /> gpol 3.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System P.levation <br /> Required Proposed Rate(Gals./day/sq.�ft.) (Min./inch <br /> ./ ) Flcru!i""ung� <br /> 7'.5-0 3.7 382.8 /•2 rV9or y 88. 1' Qd C7' <br /> �l Tank Capacity in Total H of Manufacturer Prefab Site Stec! rj�•r PI,••; . <br /> I lltnr lnation Gallons Gallons Tanks Con- Con- la1, <br /> New Existing g <br /> b 'rete strutted <br /> Tanks Tanks <br /> / 0 ❑ ❑ ❑ - <br /> ❑ ❑ ❑ �� <br /> I I Responsibility Stasi::,;;. <br /> 11 <br /> I undersigned.assume res onsib ity for installation the POWTS shown on ached .tans. <br /> it bel ignature stamps): MP PR o. — --- <br /> NMI COUNTY LINER Business Phone Nun,bcr <br /> je I Code) —_— <br /> 715-635-7482 <br /> III Counr}/Department Use Only <br /> I <br /> u Disapproved Sanitary Pernit Fee(Includes Groundwater Date Issued I Agent Signature lSu�iou,pa -- <br /> El Owner Given Initial Adverse Surcharge Fcc) <br /> Detertrumation � . u(J /yI// <br /> X. Conditions of Approval/Reasons for LtsapprovaC /leu <br /> AUG -3 <br /> 3URNETT COUNTY <br /> i<-- ZONING <br />