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commerce.wl.gov S,ft, and Huildinp Division kmaa,
<br /> 201 N'.lVazhingtun Ave„IcO.flat 7162 �_U C Pl"
<br /> iseonsin Afahson,%V153707-7162 Sannrvl'ennm Nuenher(to filled in W Cu)
<br /> Department of Commerce
<br /> Sanitary Permit Application JJ
<br /> `m"'J""tea``'°"M ",
<br /> mmandl"
<br /> In accordance with s.Co .b331(3).1Vis.Adm.Code,submission ofthis lbrm to Ne approvtiate golemmenul 225) Z 2-
<br /> .no is ¢9uired Inim m obuiming a saccon, permit Note Application room Ihr ain.nwned PONrs m, Pmlcn.\ddress(ifdill'crem than marline address)
<br /> subn ned t, the ocM1vtmell of Commerce Personal infarmutmm . pmlide ma> M tined Im amndnp
<br /> mom ,11111 me Rivmas Lmw.s. I I�u,
<br /> „�yexTn'ntU p(m7,smis. -% 2ZD�l��rranpn -�
<br /> 11nA ,alicminn Infrrnnation_I'leau frim All half
<br /> 1)1m) lmian
<br /> Pannell o,,ner',N:1me / -�� cartel a
<br /> `1L4pL./�J.4 .rLY '--!N Y06
<br /> hoperty()"Tier s ntalling Address Proven Location
<br /> 29/ O c • e— Gan Lot 1 q
<br /> Cir,Smle %ip Code Phone Number 1G, :, Sea onP
<br /> If.'I I pi,of Building(check all that apple) Iola 131 N; R_��E, v
<br /> k I ur 2 Family ITvelling-NumMr of Hnhmmra Subfivision Name
<br /> Mack a
<br /> ❑Publicicnmmestial-Dc tribe Use ❑City til'
<br /> [J State Owned-Desalhe Use sm M1'um6er ❑ Villagcof
<br /> V. 3 P. a n Tm,1n of T.a✓G_ G
<br /> IILI)pcufperal (Checknnhunebminnfine A. C°mplelelisu RifapplicabliN - 3,
<br /> A_ DNee System .rHeplin—it System 0 TcatimetMolding Trod,Replacement Only ❑(hher Modification to Existing S)stem(ecplai^)
<br /> H. C1 Permit rtemcxal ❑ PtInit Be,6iun ❑Changes Plumber ❑fermi ronsreru Nav List lteviuus Plum,Number and Data Issued
<br /> Before Expiration Oorl<r
<br /> IV.'FLL..fpo%N-1SSvslem/(-oinpunen Wevict: (Check all that n Lv
<br /> L] NomInGraand D P,css°reed In(;round ❑At-,mac ❑ Wood 174 h, nrsnlmme sell O hmmml<24 in oreallahle and
<br /> ❑ Holding lank 0Other Dispersed Comparator(explain) ❑I•retreatmcnt Rvice(caplain)
<br /> v.Dilnmsavrrealmenl Area Inrrmatina:
<br /> a d '(gN) 1851gnSer pliraGmn Ralc(glsR0 Dialn ,IA—Rryuired(s0 Di,, al Area Pmpascd(x0 S,
<br /> YS19O
<br /> TO
<br /> y :'
<br /> O
<br /> %'[.'l ook Info Ca,.sI,.a an
<br /> haul Mo( Alul'aemerr
<br /> Gallons Gallon
<br /> Nex'Taekt 4a1 InA TaNs tJ u x
<br /> i U on,
<br /> Sere,m IIOIJing Tank
<br /> WxinE CTmM SSC a^ C/✓'!� HE
<br /> °< e X
<br /> VII.Respmuibi,t,Statement-I,the unJcnili ed,assume respnnslbilit, ret,iaslallich n of lbc I.OW1 S shone...he atmcbed pleas.
<br /> Plumber's Name(Print) Ruche Signutum NY/h1YR5 Numhn Umiwss P6onc Number
<br /> C tint c / � �z sY2
<br /> Pwm�ra acres,(stiees ysmm,zip Call) /o Kz <" ���/P_✓ / D
<br /> VHI,County/De err( and Use Onh
<br /> q Approved ❑ Disapproved famitt DmeIs ed Issuin cm Signature
<br /> El Owner Given Reason for.'road
<br /> IX.Conditimss nL(ppruvBlieasons for Dizappro.al 1,
<br /> DEC�O,a rap D
<br /> JUL ] 2013}
<br /> .u.sh..............for mearn mend mLrml rotLe l'u p anly on P4'areot ksaTmB naLn In me
<br /> BURNETT COUNTY
<br /> ZONING
<br /> SBD-6398(R.02/09)Vand lhm 02/11
<br />
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