Laserfiche WebLink
Cnunry' <br /> Industry Services Division Bumeu <br /> _/°0 1• =t 1400 E Washington Ave <br /> 1 $P I I`I P.O. Box 7162 Son�inoqperiod Number H.be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State'Irm,seiorNumesa <br /> In ale ordanee eith SPS 383 21121 Wi,-Adm.Code.submivimi ofthi,tort to the appropriate gcocromental unit <br /> is required prior to obtainin,a un tan'permit Not Application foons f t t ned PORTS are soonued 1. <br /> the Dep'n t t t ly and 11 1 -onalS,ow, rsowl'tf Y m, t prm Je may be u,cd Inr swatdary. I'le t AJJnsz Of dillimvn th.ut mailing adJrea) <br /> purposes to accordance ua],the Powe%Laos bOq DIml.Sut-. 3995000N'I'YRDA WEBSTER 54893 <br /> LApplication Information-Please Print All Information <br /> No,.,Ossne,s Name Pmccl b <br /> JOS[II-A&JENNIFER HE'I VELD 07,012-2-ID-15-26-5 05,001 12" <br /> property O,mer',Slob,Addrer fresco)'I oration <br /> e20300EI AVE <br /> Govt.Lot I <br /> City,State Zip Cock Phone Number 'A, A, Section 26 <br /> 1'REDIiRIC.WI 54837 715-566-2272 (cimluone) <br /> T 40N: RIS N' <br /> 11.Type of building(check all that apply) I of d <br /> ® lerr 2 Family D,.elling-Nutnberof[led.., 2 Subdivision Name <br /> ❑Public/Camntercial-Describe Use Block a <br /> (3 Cil,of <br /> E]Man,Man,Oxnc -IXscvibe Use <br /> CShI KumMr ❑ Village al' <br /> VI 711167(0328935) ®1 nofJACKSON <br /> IIL'1' 'pe of Permit: (Check only one box on line A. Complete line B ifapplicableJ <br /> 21 Nex'S)7ein ❑ Rcplaceincnt System ❑Tremetem.1lolding l-auk Replacement Only ❑ Other ModlOcafiun to Existing Sy,om(explain) <br /> R. ❑ Permit Ranewal ❑ Permit Recision ❑Change of ❑Permit l runsicr 1.New List Por,ion,Perrin Numin:r and Dam Issued <br /> Before iixpimtinn I'lurhr (lxner <br /> IV.'I- e of POIA''I'S Svstem/Com onenUDevice: (Check all that apply) <br /> ® Nun-Pressurized lin-Ground ❑ Premniecd In-CTomol ❑ At-Gmdc ❑ Monnd>24 inofsnimble soil ❑ Mound<24 in of suitable soil <br /> ❑ Holding"rank ❑Other Dispersal Component(explain) ❑Pretreatment Des ice(explain) <br /> V.Dix per,alri'reat no to Area I form a lion: <br /> Resign Has,(gpd) Dcsigtt Sail Application Dispersal Ana Required(s0 Disttersal Are.proposed(9) c..o-m Elecmiop <br /> &op Ratelgpd,n SST 85-7Y 9No <br /> VI.Thnk Info Capacity in <br /> Uallon, <br /> '1'nu1 0or Afwulacwrcr <br /> Callum Ends, <br /> as..Tanks E.ai inti Tanks i G <br /> Septic or l lolding Tank 1250 125 WIBSGR ® ❑ ❑ ❑ ❑ <br /> losing Chamber ❑ ❑ ❑ ❑ ❑ <br /> \'ll.Hesponsibiliry'Stalement- Llhe untlrniknrd.a,. epo h' for imullotian of the PU\\'IS shnxn on the attached Man <br /> I'Iumlrcr'z Nvnm(Pring Plum 'rout M111'/MPRs Nuntbor Ilusiness('hone Number <br /> CORY JACKSON 824339 715-866-8984 <br /> Plumber's Address(Street,City,State.Zip Code) <br /> 9306 BLACK BRf aCK RD. WEBS'IER, WI 54893 <br /> VIII.County/Depar ora nt Use flak <br /> APPro.eJ ❑ UisaPsrove-J Permit Fee Jet,MueJ IsaiingAgumsign.mre <br /> ❑ (honer,Divan Reason r Denial s 3z Soo P-L4•/�/ <br /> I.C.Conditions of Approval/Rcasoas for Disapproval <br /> 4y9rX;*2 NOT oppiE a.El- a 6a.✓Rne4 Sia o"72;-- A[o .TD EaEME <br /> 3iDeM w9TER 2tfNOFG/7clKT/1E <br /> p AUG 21 2014 <br /> ovum n,coomere 116..ra.me,.,temana,uhmbmmrcaa _ a.y'an p.prr am lz,tn.netr to a.. <br /> BURNETT COUNTY <br /> SBD-6398(803/14) ZONING <br />