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o - County /J <br /> Safety and on Ave., Division I^1//J <br /> 201 W.Washington Ave.,P.O.Boz 7182 Saviraty Petmit Number pe-be filld in by Co.) <br /> e Madison,WI 53707-7162 <br /> �•.u�s <br /> Sanitary Permit Application Spite Transaction Number C3 <br /> In acromancn with SPS 383.21(2),WLR Adm Code,submission of this form to the.,ro o rte governmental unit <br /> is"prel prior to obtaining a sanitary pmni, Note:Application forms for state-owned POWTs aresnbminN in Prejeet Address(if different than mailing address) <br /> the uses in <br /> ve of Safely and Professional Service. Personal sure. anon you provide may be used for smoraiary ��C <br /> u plolariveInfo wish the-mac few,s.t All 1 m malts. T7Jt� Kru er R1- <br /> I. Applications Information-Please Prim All Information <br /> Property Owner's Name Pared k <br /> 50 rd, 6 o �c Vit : , D7-0)F- 3-401-60D-Dn <br /> Pronperty Covert',Mailing Addles y� p Property Illon <br /> ati <br /> L,1 / s / Govt Lot <br /> City,Sate Zip Codr Phone Number AL y,,AESC a, Scuieo <br /> we fe r L✓ `+ 893 7/5-86 -4 9 37 °�leO°/",�,�, <br /> 11.Type of Building(check all that apply) Und TSN; R�y_E os.!' <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> BI«k k <br /> ❑PublievCornmemial-Describe Use <br /> ❑Ciry of <br /> El Stop Owned-DescribeUse CSMNumber O Villageof <br /> 3Toxmaf Mr.e^✓I4271 <br /> 111.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. O New System sq Re,dre went System O TrcmmenVHolding Tank RWlauetnent Only O Other Modification w Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Prnnit Revision O Chavge of Plumber ❑Permit Transfer to New List Previous Permit Nernberand Date board <br /> Before Expiration Owner <br /> IV.Type of POWTSS stem/Com onenNDevice: Check all thetapply) <br /> b�NOn-Prosunxd ln-Ground O Pressurized In-Ground O Aso mde O Mnud>24 m.i f suitable soil O Monts<24 in.of suitable soil <br /> OBoiding Tank GOther Dispmsal ComWnent(cxp1mtd - ❑Pectmament Deoei,(explain) <br /> V.Dis ersahTrealment Area Information: <br /> Design Flaw(gpd) Design Soil Application Rate(gpdst) Dispersal Arca Retailed(s0 Dispersal Ates Proposed is,I System Elevation <br /> . 7 SS7 `7 + • 7 9 8-%11 <br /> VI.Tank Info Capadry in Total 07 Manufacturer <br /> Gallam Gallons Unity $ - <br /> NewT.Ass Frim.,1'a,Js `° '^ - 'd. - <br /> E U - 2 u JJE <br /> See is or HoW(ng Tank I Int '� D ) J <br /> DiNax Chamber f GV „ 75 p 1 Yw <br /> VIL Responsibility Statement- I,the undersigned,assume resp°mibilih for inslallstion o(the POWIS shasrn on the anachd plans <br /> Plumbers Name(Print) Pimaba's Si MP/MPRS Number Business Ph one Number <br /> ll f FF q vl/ 750310 7/s-� , <br /> Plumbers Address(Street,City,State,Zip Code) <br /> v✓/°ly% tic E s .00 l <br /> 5— <br /> Vi[II.CoulayflIepartiritiont Use Om ' <br /> Approved ❑ Diseppmved Penins Fee !D Date II mud beer s Si inure <br /> ❑Owner Givea Reason for Denial 53�. J/ <br /> IX.Cendlhona of ApprovaVReasons for Disapproval <br /> �C���M[ <br /> Amen m wmplete plata for me entero em submit to mD.Coun,only on foramina leu than eta a 11 Imhei <br /> BURNETT COUNTY <br /> SBD-6398(R w'l) ZONING <br />