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Cramy <br /> Industry Services Division y„ <br /> = 1400 E Washington Ave Arran It I Nninber(n be f I,d m by C,) <br /> \;S PS.. `I'i P.o. Box 7162 -�f/G/V�/I�rlXv/n <br /> `�•., \ �.�' Madison,WI 53707-7162 -/ <br /> Sanitary Permit Application $N1f T""'"Cllr.Member <br /> In accordance with SPS 383 21(2),Wo,Adm.Code,submission of this Poen to the appmpniae guvemmemal unit <br /> ismquiredpnor[orbtuining a sanimry permit. Not,Applrehire lbrms forsmte-owned POo`TS aresubmidedto Pre tAAdmss(,I dilTerentaham hailing addro's) <br /> the Department of SaRry and Pre essionel Se'res. Pretreat infanmatinn"m provide miry be,owl fir"reondary <br /> harasses in accordance with the Pnvacv Ltw,s.I5.04(1)(mh Stars_ A <br /> L Application Information-Please Print All Information <br /> Print Owners Name pians030-3-4U-/b-d / a <br /> J r.r l3 to r. oro. old cea <br /> Property O <br /> wnersMaday Addrens Pmpary Location <br /> (p 6/J /?"V, Govt.Lot Fla /j <br /> Ciry,Slate Zip Code Phone Number �Y. Q/�r �p Section 47 <br /> ^� (circle aree)) <br /> l.✓f. f S'3 1 NO N: R /[ Eort <br /> II.Type of enildimg(check all that apply) Lot ft <br /> I ort Family Dwelling-Numbefof6edromus Subdivision Name <br /> Black st <br /> D Pulthe/Commernal-Desenlae Use <br /> ❑ Ciry of <br /> ❑Sore owaad-DescbeUse CSMNun,ber ❑ Vdlasror <br /> [YTown of 06 r /a ee"/ <br /> 1 LT,pe of Permit: (Check only one hos on line A. Com Plete line 11 if applicahlie <br /> A' L1 Neve System rReplaeetnen[Syrtan ❑Trehraahtrihdim,Tank Replacement Only ❑ Other Mrdidcationm Existing System(explain) <br /> R. ❑ Pmnit Renewal ❑ Penni[Revision ❑Change of Plumber ❑Permitam, <br /> TfNcm New List Pr muc Permit Numbcrand Ratelssned <br /> mer ne Expimtmv ownrr os-S-5"$ lH E-/976 <br /> IV.'I v c of POWfS Svstem/Cont onenUDevice: Check It])that a Iv) <br /> Non-Presun'zed ImGroond ❑ 1hp,mized IroGmund ❑ AtGrade 11 Mound 24 in.ofsuimble soil ❑ Monona<24 in,efsuitable soil <br /> ❑ Holding 9'ank ❑Other Dispersal Component explain) ❑Pretreatment Desire(rxplain) <br /> V.Dis c sal/1'rie tmnot Area Information: <br /> Reston Flow(gqp Ihegn Soil Ap 1.nah n Ra,,O dsp Dispersal Arcs Requited(It) Dispeetnl Area Papered(sr Synem Elevation <br /> A/✓r0 G 4/3 GS7 9.7.0 l e Sa p <br /> VI.Tank Info Capacity an Tnml p of Manufacturer <br /> Gallon Griot, Units <br /> Newranks Gntin6 Tanks <br /> `Jco as <br /> czG <br /> Septic or Hitting Tank /BOO xx s/Cit.w x <br /> Dosing Clamber <br /> VII.Responsibility Statement- hthe undersitmed,assume reaponsihilin'for insmllmion afthe PORTS man met he marched plans. <br /> Plarmor's Name(Print) I•lumbefs Signature NIPIMI'RS Norman Business Phone Number <br /> 'P+G/G /,/"/,. � J �-�+ W dds6.s`/ 71J%8G(-y/J' 7 <br /> Plumber's Address(Smect City,State,Zip Coda) <br /> 7 7a a /! .es' &/{S a r(<i _SY89-3 <br /> VIII.Crinty/De at(an mat Use Onb <br /> �Airport ❑ Daapprovea Pennic Fee ilmehosed Issuing Agrnt Sigrmnmv <br /> 3zs n� 8- y <br /> ❑ Owner Given Reason for Denial /q( <br /> IX.Conditions of AppfovallReasons for Disapproval <br /> SF .f/EIa LEtc 7a er-0" 2 sx/s7�u, rn�7- 9-1- D ����V LS <br /> DEEP �jua/,wN 7D I?E aoc.v�p ir/ /,t/-r/Tu Sa/L. <br /> nunmw 'an,emm nor me m and ainmiuome Ca unto..........In:meaeu rut b <br /> C57-I�I-6a <br /> BURNETTGOUNTY <br /> SBD6398(80313) - ZONING <br />