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!�G, rCounty <br /> 11" -1 z1 Safety and Buildings Division <br /> � '0SP <br /> rI 201 W.Washington Ave., P.O. Box7162 5anitary Ycrmit Number(m be f�Iled in by Col <br /> ?S Madison,WI 53707-7152 <br /> - <br /> Sanitary Permit Application Sure Tmmaction.Number <br /> In accordance with SPS 353?I(2),W is.Adm.Code,sadmission of tMs form no the appropriate governmental unit <br /> is prior o obtaining a sanitary permit. Note:Application forms ton stats-lone POWTS are s.bminedla Project Add....(if dlRo,ent mucanchng address) <br /> he 1),unn un of Soo,and Professional Servies. Personal information you provide may be used for secondary <br /> numoses in accordance with the P,ivacv Low,s. I5.poll on St., 58//JIC <br /> 1. Application Information.-Please Print All Information <br /> Property Own�e,'s JName-,�.r. - Priced TA �4 <br /> FOb�- E fLo'R ST20rv1 <br /> Propery. Owner's Moiling Address Property Location <br /> IZB 1 �t �wooG� LF n& <br /> Gout Lest <br /> City,Sta¢ Zip Cmde Phpne Number g Y�.(,C$�re`ctimn /$ <br /> o6nCfL l S I�OI (alt-Yl5- 7 /91 34 N, R all <br /> II.Type of Building(check all that apply) Lorp <br /> I ort gamily lJxelliag-Numbaoffi,cmoms 411, Subdivisian Name <br /> Bl -l-rt1 OUTLo? GfI�L Aa/Oo �' NR'/srn /c <br /> ❑YubLc/Commercial-0cscribe Use ❑City of - <br /> 171 State Owned-Describe Use CSM Number ❑ village of <br /> roof 1<.uas✓i <br /> IIL I'rpe cf Permit (Check only nne bac on line A. Complete line B ifapplicabla) <br /> A. . NovSyeam Y'Re la"ah"iS <br /> p ystem ❑TreaunercJH.lding Tank Replacen¢m Only ❑ Other Modification to Exls.ng System(explains) <br /> B. ❑ Pinant Renewal ❑a rnh Revision ❑ CM1ange of Plumber Ll Permh Translb;mNew, List Yrc✓i.us Perme Nuc.ber and Data Issaetl <br /> _Before Expimticn 'eI_,Y� Owner - <br /> r_ ' — /Z•74Y— -10-/7- --- - <br /> IV.Tvfl,of POWTS Swemi-arn omen Werire: Cheek all that a Iv) <br /> xNon-Pre,sri In-Gmnnd ❑ Pressurized h.Ground ❑ At.GAde ❑ Mc„d>z:in at suitable soil ❑ Mound<x in_of.uitamecall <br /> Holding Tonk ❑Other Dispersal Comp.nent(espluin) ❑Pretreatment Dcvac(explain) <br /> V.1)is crsal/freatment Area Information: <br /> Deslgo Flow(gpd) Resign Sail Application Rate(epdst) Dispersal A:ce Reaction](sf) pispersal Arza Proposed(sl) System Elevation <br /> 300 - C loll, <br /> VL'1 ark Info CGacon In Total qoi Manufacturer <br /> Gallons Gallons 'Jolt G v <br /> 1—TVMs Fxiaiaa Teab <br /> cU an7 - : o <br /> S:Plc o�Jfek:n5 Tal 700-SOO <br /> oo,n'a Cna:nnR /000 / �KRa[� p4TtT1�I <br /> Vll. 11ca.ncihillty Statement- L the undarsig ed,asm e,ponsibilt rms alletion a rk,POWTSshow a the attached plans. <br /> Plumber Name(Print) PI sSig no MP/MARC Number BusinessPhoneNum- <br /> m(l er .aur d _ — &K SEPTIC & EXCAV TION <br /> Plumbers Adan (Smeet,Gay.rota zip Inde) OAD <br /> SPOONER, WI 54801 <br /> N Ill.Counrol0e coherent Ose Only - <br /> Asp rmed ❑ Disapproved P .f Done Issued I"Lad A msignawre <br /> ,I. <br /> El Ohms,Given Reasonfcr Dental $3a S.L -7-/ 1-- k.l <br /> 10— <br /> JX.C.di hien,of Apprm,rl/Reasons..r Brsappr.hot <br /> WELL 10097-led lour pEPic7r-p div pawn Ta.�,e� egi anti D E(flU�i1 OMIS <br /> insET �vv feT/PylKS v <br /> un@m mpine plxm for,ne tom xnJ UNmrt ro,l¢Coun,y nnl�nn Pape nm ltaf tFxn 81/ir 11 in <br /> is 6e <br /> C5T I�-53 <br /> all. 1In 1) BURN ETT COUNTY <br /> ZONING <br />